Public APIs getting ready for prime time

'Any system that wants to implement these open specs can run these apps in any way they like'
By Neil Versel
11:15 AM

At the American Medical Informatics Association's annual symposium today, developers and backers of public application programming interfaces talked about how the standard could speed interoperability with add-on apps to enterprise EHRs, and help make those bulky systems more nimble.

In a recent draft of its 10-year roadmap toward interoperability, the Office of the National Coordinator for Health IT adopted a recommendation from its JASON task force that Stage 3 of meaningful use include public APIs. The first such API likely would be Fast Healthcare Interoperability Resources, or FHIR (pronounced "fire"), a standard being developed by Health Level Seven International.

[See also: Interoperability's 'game-changer']

On Tuesday at AMIA's annual conference, fans of FHIR discussed a federally funded test implementation of the standard, and what it might mean for moving the needle on interoperability.

Widespread adoption of FHIR could make the EHR a "potentially open platform," much like Facebook or, said David McCallie Jr., MD, director of the Cerner Medical Informatics Institute, and a co-chair of the ONC JASON task force. "This notion of a platform is something we’re very comfortable with now."

[See also: Go easy on Stage 3 MU, says JASON group]

Apps built on an open API would extend the platform, he explained.

"It's also, for this crowd, a new channel," McCallie said to this meeting of medical informatics professionals. It would be an alternative to manipulating the source code of an EHR, which he said few CMIOs get to do these days anyway.

McCallie quoted the CEO of an unnamed integrated delivery network  one he said was not a Cerner customer  who said he wanted an open, extensible platform because EHRs were becoming commodities. If a system vendor doesn't work out, proprietary APIs can cause "vendor entanglement" McCallie said, in what may have been a dig at Epic Systems.

McCallie and other panelists then demonstrated "SMART on FHIR," a vendor-neutral implementation developed with the help of a $15 million ONC Strategic Health IT Advanced Research Projects, or SHARP, grant.

The SMART – for Substitutable Medical Apps and Reusable Technology – platform architecture consists of a user interface to "allow 'iPhone-like substitutability for medical apps based upon shared basic components," according to the project's website, as well as a collection of scaleable data capture, storage, retrieval and analytics apps. Apps can launch directly from an EHR when a clinician clicks on an alert.

"Current app stores are not that good for healthcare," McCallie said of public ones such as iTunes and Google Play. SMART on FHIR is meant to replicate those stores, but with a much narrower focus.

"Any system that wants to implement these open specs can run these apps in any way they like," explained Josh Mandel, MD, lead architect for the SMART Platforms team at Boston Children Hospital's and Harvard Medical School.

FHIR is a means of representing structured clinical data, one that "models the world of structured clinical data," according to Mandel, and contains more than 50 medical "structures," each defined by a set of data types.

This "restful API" draws in data with an HTTP "get" request, he explained. "This is a concrete data payload," Mandel said. "It can be understood by someone who's never read an HL7 standard," he said.

FHIR uses the OAuth standard for authenticating users, then builds a "clinical picture" based on specific data elements that individuals want to fetch from various repositories, Mandel said.

In a live demonstration before an overflow crowd in a too-small meeting room at the Washington Hilton., Mandel showed a pediatric growth chart in use at Boston Children's that has separate views for clinicians and parents.

McCallie said the Cerner pediatrics team was "floored" when they saw the parent view. "That's what happens with apps," he said.

A medication app currently in prototype stage can pull a patient's medication profile out of the Cerner Millennium EHR, McCallie said. It also can translate patient instructions into any of at least 17 languages and provide a printout in the patient's native language, not just English or Spanish. "This is another place where we can go deep and deliver something we haven't developed (at Cerner)," McCallie said.

This is in the pilot stage, though McCallie said it should be in production next year when HL7 officially publishes the specification profiles. This will lead to "friction reduction" by not having to argue over the API to use, he said.

Kenneth Mandl, MD, chair of biomedical informatics and population health at Boston Children's, said he connected with Cerner and with Utah's Intermountain Healthcare at HIMSS14, and saw they were using open APIs. He said he wants to have a SMART on FHIR demonstration at HIMSS15 in April using data from "real patients."

Mandl first conceptualized SMART in a 2009 New England Journal of Medicine essay he co-authored with colleague Isaac Kohane, MD.

Not all are ready to anoint SMART on FHIR the savior of health IT interoperability, though.

In an earlier session Tuesday that McCallie also was involved in, NextGen Healthcare Information Systems CMO Sarah Corley, MD, urged caution with FHIR, at least when it comes to including it in the upcoming meaningful use Stage 3 regulations. "FHIR is a draft standard," said Corley, who also serves as vice chair of the HIMSS EHR Association. "We don't want to require something before its time."