Modern Interoperability: How APIs Can Heal a Fragmented System

I was getting my annual flu shot at my local pharmacy recently and the visit served as a microcosm of healthcare IT at the front lines. My vaccination was seamlessly registered in both the pharmacy’s online system and the state HIE, the IT worked as intended. Meanwhile, another customer was engaged in a long discussion with the pharmacist over inconsistencies in the duration of her chronic medication prescription, caused by computerized payment rules and resulting confusion over the copay. Multiple trips to the pharmacist’s computer were needed to come to some quasi-reasonable resolution.  Here, modern interoperability was clearly missing. One could easily imagine a few API connections between that patient’s EHR, e-prescribing system, PBM, and the payer that could have eliminated this frustrating back-and-forth. 

Today, the clinical and financial complexity of the American healthcare system begs for computerized communications that deliver efficient service without needing human intervention. Every other major service industry has sorted this out: for instance, when was the last time you had to speak with someone at Amazon? That raises 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 the payment for that care – not literally from birth, but since the 1942’s World War II Stabilization Act which made healthcare pre-tax and therefore employer-based. Removing the patient as the direct purchaser of care has created a lasting disconnect between clinical care delivery and market discipline in pricing and access. The result has been the balkanization of healthcare IT, as economic participants optimize for their own reimbursement environments rather than for providing value to patients. We now see large delivery systems consolidating to gain pricing leverage over payers, PBMs behaving like PBMs, and payers trying to walk the line between volume and “value-based” care (value for the payer, not necessarily the patient). Many of these business models actually rely on fragmented IT to sustain opaque and at times anti-competitive business practices.

Meanwhile, in the rest of our consumer-choice lives, competition thrives on effective APIs that deliver instantaneous service and communications – whether in shopping, travel, finance, or entertainment. In healthcare, these same digital expectations are increasingly being enforced through government policy. The 21^st Century Cures Act of 2016, for example, requires APIs that enable access “without special effort” and prohibits “information blocking” among providers, EHR vendors and networks. Building on that foundation, HHS agencies, including ONC and CMS have issued multiple regulations – from the 2020 ONC Cures Act Final Rule to CMS’s 9115 and 0057 rules, and now the HTI4 requirements – all of which push for true counter-party interoperability through standardized APIs.   

While some incumbents argue about and lobby against laws and regulations requiring modern interoperability, the more important interoperability dynamic will be the twin pincers of public disgust with the healthcare costs and the increasing delta between cellphone-driven consumer expectations and healthcare system performance. Is it even possible to shop for care on your phone? Is it possible to appeal an adverse prior authorization decision from an app? Can you engage in a meaningful conversation with your payer using an app? 

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

While we wait for payment reform and the next tranche of interoperability requirements to eliminate such interactions, it will be important for providers and payers to think about their roles in an increasingly “API-first” modern digital world. Whether through high-deductible plans, increasing co-pays, or requirements for providers and payers to enable apps, consumers will increasingly gain and exert choice. APIs are touching providers and payers in provider-payer and payer-payer interactions, as HHS agencies (CMS and ASTP/ONC) have requirements for these coming up in just over a year.  

APIs that power modern communications are increasingly available. Well-written code and well-architected enterprise software should readily support multiple API-driven business strategies. Modern interoperability is built on RESTful APIs and JSON – and, in healthcare, on a specific instantiation, FHIR. These are well-understood and widely adopted technologies; indeed, the entire cellphone app economy runs on RESTful APIs and JSON. We should be working to eliminate faxes and fax equivalent (or worse) technologies such as TEFCA, which are ultimately designed to generate friction.  Modern algorithms can do far better than friction in allocating care.

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

Amid the ongoing political drama on how to pay for healthcare, many federal policies, including Medicare Advantage and managed Medicaid, are forcing active care-allocation decisions. The go-to mechanisms for differential payment – network design, case management, quality measurement and prior authorization – increasingly rely on APIs capable of handling not only claims data but, more importantly, the clinical data critical to intelligent decision-making. APIs will enable and drive these seamless communications.  

U.S. healthcare: welcome to the modern, “API-first” world.

Photo: nevarpp, Getty Images

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