Modern Interoperability: How APIs Can Heal a Fragmented System

I recently got my annual flu shot at my local pharmacy, and the visit served as a microcosm of healthcare IT on the front lines. My vaccination was recorded seamlessly in both the pharmacy’s online system and the state’s HIE, the IT worked as expected. Meanwhile, another customer was engaged in a lengthy discussion with the pharmacist about inconsistencies in the duration of her chronic medication prescription, caused by computerized payment rules and resulting confusion regarding copayment. It took several visits to the pharmacist’s computer to reach a near-reasonable resolution. Here, modern interoperability was clearly lacking. One could easily imagine a few API connections between that patient’s EHR, the electronic prescribing system, the PBM, and the payer that could have eliminated this frustrating back-and-forth.

Today, the clinical and financial complexity of the U.S. healthcare system requires computerized communications that provide efficient service without requiring human intervention. Every other major service industry has solved this problem: for example, when was the last time you had to speak with someone at Amazon? This begs the question: why hasn’t healthcare achieved the same level of seamless digital interaction?

Our payment system was designed to separate the provision of care from paying for that care – not literally from birth, but since the World War II Stabilization Act of 1942, which made health care pre-tax and therefore employer-based. The removal of the patient from the status of direct purchaser of care has created a lasting disconnect between the delivery of clinical care and market discipline regarding price and access. The result has been a balkanization of healthcare IT, with economic actors optimizing their own reimbursement environments rather than delivering value to patients. We now see large delivery systems consolidating to gain leverage on payer prices, PBMs behaving like PBMs, and payers trying to cross the line between volume and “value-based” care (value to the payer, not necessarily the patient). Many of these business models actually rely on fragmented IT to support opaque and sometimes anti-competitive business practices.

Meanwhile, in the rest of our consumer lives, competition thrives through efficient APIs that provide instant services and communications, whether in shopping, travel, finance or entertainment. In the field of health, these same digital expectations are increasingly implemented by government policy. The 21st^st The Century Cures Act of 2016, for example, requires APIs that enable access “without special effort” and prohibits “information blocking” between providers, EHR providers, and networks. Building on this foundation, HHS agencies, including ONC and CMS, have issued several regulations – from the 2020 ONC Cures Act final rule to CMS Rules 9115 and 0057, and now the HTI4 requirements – all of which push for true counterparty interoperability via standardized APIs.

As some incumbents debate and lobby against laws and regulations requiring modern interoperability, the most important interoperability dynamic will be the twin pincers of public disgust with health care costs and the growing gap between mobile-driven consumer expectations and health system performance. Is it even possible to purchase treatments on your phone? Is it possible to appeal an unfavorable prior authorization decision from an app? Can you engage in a meaningful conversation with your payer using an app?

As a patient, I spend about a hundred hours a year on hold trying to communicate with “call centers”. Hearing repetitive “Mr. Donald, we appreciate your patience while we…” messages every 15 minutes from an employee in an outsourced call center on the other side of the planet juggling 2 or 3 other customers also on hold is not satisfying. This is especially true because as an insider I know that the underlying conversation is both clinically and economically unnecessary.

As we await payments reform and the next tranche of interoperability requirements to eliminate such interactions, it will be important for providers and payers to consider their role in an increasingly API-first modern digital world. Whether it’s high-deductible plans, increased co-pays, or requirements for providers and payers to enable apps, consumers will increasingly have more options and choices. APIs affect providers and payers in provider-payer and payer-payer interactions, as HHS agencies (CMS and ASTP/ONC) have requirements on them in just over a year.

The APIs that power modern communications are increasingly available. Well-written code and well-architected business software should easily support multiple API-based business strategies. Modern interoperability relies on RESTful and JSON APIs – and, in healthcare, on a specific instantiation, FHIR. These are well-understood and widely adopted technologies; indeed, the entire mobile app economy runs on RESTful and JSON APIs. We should work to eliminate faxes and equivalent (or worse) technologies such as TEFCA, which are ultimately designed to generate friction. Modern algorithms can do much better than friction in care allocation.

Consumer-facing API strategies are complex and will ultimately need to integrate with the concept of the “connected self” as patients become increasingly motivated to maintain their health. However, provider-payer value-based contracts can immediately benefit from modern RESTful APIs that enable shared real-time or near-real-time communications between payers and providers.

Amid the current political drama over how to pay for health care, many federal policies, including Medicare Advantage and Managed Medicaid, mandate active care allocation decisions. The essential mechanisms for differential payment – ​​network design, case management, quality measurement and prior authorization – increasingly rely on APIs capable of managing not only claims data but, more importantly, the clinical data essential for intelligent decision-making. APIs will enable and drive these seamless communications.

Healthcare in the United States: Welcome to the modern, “API-first” world.

Photo: nevarpp, Getty Images

This message appears via the MedCity Influencers program. Anyone can post their views on healthcare business and innovation on MedCity News through MedCity Influencers. Click here to find out how.