The Office of the National Coordinator for Health Information Technology (ONC) is pinning its latest hopes for interoperability on the cloud, namely with application programing interfaces, or APIs. But is this hope realistic?

Experts feel it will be a close call to get the API standards ready in time for requirements found in the April 27 release of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) proposed rule. The rule makes it a national objective to achieve health data interoperability by December 31, 2018.

A measure in the MACRA proposal called, “View, Download, Transmit (VDT),” calls for eligible clinicians to help patients:

  • view, download or transmit their health information to a third party;
  • access their health information through the use of an API; or
  • a combination of both.
HHS Headquarters in Washington, D.C.
Brian M. Kalish/Employee Benefit Adviser

In an April 27 blog, Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services (CMS), gave an indication of ONC’s hopes for APIs, saying they will “open up the physician desktop to allow apps, analytic tools, and medical devices to plug and play.”

Setting apps on ‘fire’

There’s one problem with that. The APIs aren’t ready yet. HL7 (Health Level Seven International), a group that sets standards, formats and definitions for exchanging and developing electronic health records (EHRs), is working on standards for healthcare APIs called Fast Healthcare Interoperability Resources (FHIR). It’s pronounced "fire,” and there are plenty of references to FHIR setting the whole health app world on fire.

Gary Dickinson, co-chair of HL7’s EHR workgroup believes that ONC is maybe putting too much pressure on HL7 to get the APIs completed by 2018. He thinks FHIR will “probably” be ready in time for what is required in the MACRA proposal, but not for broader use. Some companies in the industry may go ahead and use the FHIR standards prior to HL7’s vetting them, he said.

Developing FHIR standards for APIs is not an easy thing to rush. FHIR divides data into “bite-sized chunks” for transmission. These are called resources. FHIR has more than 100 different resources identified. Each of these must be vetted, involving more than 50 workgroups at HL7. Developers rate each resource with a maturity level of zero through five. Most resources today are rated zero or one, Dickinson says.

HL7 is shooting to have the third in a series of trial versions of FHIR ready by Dec 31, but that is likely “pushing it,” he says. The timeframe largely depends on the number and extent of updates required from comments received in the upcoming August FHIR ballot.

John Halamka, MD, chief information officer of the Beth Israel Deaconess Medical Center, Harvard medical professor and co-chair of the HIT Standards Committee says FHIR is key to the future of query/response interoperability, which allows users to pull the data from wherever it resides.
“We’re at a time in history when the private sector--driven by customer demand--is implementing novel solutions to healthcare information exchange,” Halamka says. “FHIR is already in production in many applications and every major HIT vendor will have FHIR application program interfaces in production this year.”

Is ONC pushing too hard?

Justin Barnes, health IT industry advisor and thought leader, doesn’t think ONC is necessarily trying to force the use of APIs in the new MACRA proposal. Barnes has been an advisor to the White House and has worked with Congress and regulatory agencies on health IT issues for more than a decade. His interpretation is that ONC officials are trying to mandate flexibility, usability and interoperability. “I don’t feel they’re pushing for regulatory granularity,” he says. “They want to allow creativity.”

Robert Tennant, director of health information technology policy at the Medical Group Management Association agrees that ONC is not forcing the use of APIs in its MACRA proposal, but “it’s clearly in there.” For Tennant, it all comes down to one thing--“trying to find a balance between what patients want and what doctors can handle.”

“The government would say that interoperability is the seamless flow of information,” Tennant says. “But the question is, does every record need to be interoperable? Probably not.”

David Kibbe, MD, is president and CEO of DirectTrust, a collaborative non-profit association of 145 health IT and healthcare provider organizations in support of secure, interoperable health information exchange via the Direct message protocols. Kibbe is also a senior advisor to the American Academy of Family Physicians. He says with the use of FHIR, APIs will help patients get a fuller picture of their own health information, because the apps will help them access it and see it in new ways. But some aspects of developing FHIR are going to be difficult, especially with cross-organizational use cases.

Of the MACRA proposed API requirements, Kibbe says, “it will be an enormous challenge for both providers and vendors to meet the new objectives and measures within the current time frames, with all the other additional objectives and measures required.”

Bipartisan optimism

At a May 11 House Ways and Means Committee hearing on the MACRA, Slavitt said the proposal is just a starting place for the discussion. “It will take work and broad participation to get it right.”
MACRA was a bipartisan effort, and true to those roots, optimism about the proposal was also bipartisan at the hearing. Rep. Ron Kind (D-Wisc.) said MACRA is “all about finding ways to care for patients.”

Rep. Peter Roskam (R-Ill.) said, “we’re on the verge of good things.”

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