Two years ago, we published a report on the promise of open APIs in healthcare. In APIs for a Healthcare App Economy: Paths to Market Success (available as a free download), provider organizations told us that developing and using APIs was low on their list of priorities. Modern REST-style APIs were still not on the radar for most providers and payers.

Back then, HCOs large and small said they expected their EHR vendor to build an API infrastructure for them. Two years ago, only Allscripts and athenahealth offered an app store along with a comprehensive developer support program. At that time, the other EHR vendors were slow-walking FHIR support and had vague plans for app stores and developer support programs. We found that:

• Small HCOs were completely dependent on their EHR vendor.
• EHR data was the most valuable data resource in healthcare.
• Large IT vendors had varied beliefs about the role and contribution of third-party developers.
• Large and small IT vendors had strong faith in open APIs.
• Small and independent IT vendors were thinking way beyond the EHR.
• Physician dissatisfaction with EHRs was an unsolved problem.

Since then, market conditions have continued to change. EHR vendors are now more vocally rolling out the API infrastructures that will bring healthcare into the mainstream of 21^st century computing. Every major EHR vendor has delivered a variety of proprietary, HL7, FHIR, and SMART APIs along with the ability to leverage REST to improve their products.

Each of these companies sponsor, or will soon sponsor, an app store for third-party innovation. This has seen a concurrent rise in interest for using APIs within provider organizations. A recent Chilmark report, Healthcare App Stores: 2018 Status and Outlook, examines some of these platforms and the progress that has been made to date in more depth.

That said, some things have not changed. EHR data remains the most valued data resource in healthcare. All but the largest provider organizations are dependent on their EHR vendor for API enabling technologies. Small and independent developers struggle to participate in app stores and EHR developer support programs, despite great ideas for better apps to improve care delivery. And physician frustration with EHRs continues to grow.

Developing and using APIs is a priority for healthcare stakeholders who want to get more from their EHR investments as they identify opportunities for workflow improvements, real-time analytics dashboards, and more. While EHR vendors are leading the charge, our more recent research suggests that many other stakeholders hold or control access to other key data sources that could underpin such efforts.

The opportunity to capitalize on data already collected to provide advice and predictions is too big to ignore, and the easiest way to do this efficiently will be with integrated apps that can pull data from any relevant resource to provide the necessary insights at the right time.

Where do we go from here?

The number of apps in EHR app stores grows monthly. To date, the idea of the potential role and benefits of an independent certification body has not entered the discussion about APIs and app stores since the collapse of Happtique’s efforts in 2013. Currently, EHR vendors certify apps for their customers based on rigorous internal evaluations, but the process varies by vendor. An independent and impartial body could do more than just provide information for prospective users. Instead, it could deliver tremendous value if its assessments were multi-pronged and supplied information about the ongoing use of the app, as well as a consistent way to think about safety, security and dependability. While a certification authority could make it easier for decision-makers, the real value could be in delivering users more information about how the app delivers value across its install base.

Sometime in the next few months, the ONC will issue new rules on information blocking and what constitutes an API that does not require “special effort” to access and use. While these actions may seem like a watershed moment for health IT, the provider market has moved perceptibly since ONC began its rulemaking. Just two years ago, providers were curious about APIs and app stores but they weren’t ready to make any commitments.

Slowly and inexorably, healthcare is embracing the downloadable app as a tool for innovation and improvement. One-size-fits-all platforms are not meeting the needs of the industry and apps can do more to assist with care provision needs than just provide supplemental functionality – to read more about opportunities for apps to have significant impact, take a look at the infographic we developed to accompany our more recent report, or read more in this deep dive post from June.

The opportunity to capitalize on data already collected to provide advice and predictions is too big to ignore, and the easiest way to do this efficiently will be with integrated apps that can pull data from any relevant resource to provide the necessary insights at the right time.

In a recent fit of insomnia, I downloaded a free Electronic Arts version of Scrabble onto my Android phone. I made my decision based on four things: The name of the app, the name of the developer, its star rating in Google Play, and the user reviews, which offered a warning about annoying ads that I chose to ignore.

However, the ads proved to be too much – as was the fact that the app didn’t work in airplane mode, which meant I couldn’t play while flying or otherwise trying to conserve my battery. After a few games, I uninstalled the app and (eventually) fell asleep.

Consumers in the market for health and wellness apps find themselves in a similar situation, only with a lot more choices – and hopefully without the insomnia. Last summer, IMS Health reported that there were more than 165,000 apps; only a fraction are for clinical use (see chart).

For all the apps on the market, remarkably few curation services exist. The first, Happtique, abruptly shut down in late 2013 once a developer discovered glaring security holes in multiple apps that had been approved – confirming the suspicion Chilmark Research had raised several months before about Happtique’s viability as a health app marketplace that was also serving as its own regulator.

Health app curation services that have emerged since fit into three categories:

• Those available only to customers or registered users – SocialWellth, Cigna’s GoYou (now part of Health Matters and built in conjunction with SocialWellth), Jiff Health, and HealthTap.[1]
• Those geared to medical professionals – IMS Health’s AppScript and the iMedicalApps website.
• Those available to patients at forward-thinking providers such as Ochsner Health System.

The rest of us, then, are left with same vague, subjective, and incomplete criteria on which I based my 1 a.m. decision to download Scrabble – app name, developer name, star rating, and user reviews – to decide which app is the best choice to manage their fitness, diet, diabetes, hypertension, fertility, or any other condition substantially more important than a letter tray full of vowels.

The latest app curation initiative – Ranked Health, out of the nonprofit Hacking Medicine Institute – takes a different approach, rating apps much the same way that academic medical journals peer-review research. Reviewers study the apps independently, then sort out their discrepancies before posting a public review. Each review is written like an FAQ, describing the app’s intended use and rating its clinical effectiveness, functionality, and usability accordingly.[2]

According to Dr. Maulik Majmudar – cardiologist and associate director of the Healthcare Transformation Lab at Massachusetts General Hospital and one of Ranked Health’s two senior editors – Ranked Health is focused at the outset on a systematic, rigorous, and transparent methodology for judging an app’s clinical value, rather than on app ratings themselves. That’s because both consumers as well as physicians want recommendations they can trust. Star ratings may work for restaurant reviews or free games, he said, but they won’t cut it for clinical use cases.

Ranked Health’s current footprint is small – 17 apps reviewed as of May 6 – and it will need to scale its peer-review model rapidly to make a dent in the market, which by now is probably close to 200,000 apps. It also needs to forge partnerships with HCOs, professional organizations, and anyone and everyone that can influence how consumers choose health apps. (To be fair, Ranked Health said it plans to both, and to expand its reach to wearable devices as well.)

The failure of Happtique, the stasis of the National Health Service’s Health Apps Library, and the limited availability of existing health app curation services all present Ranked Health with ado n opportunity to fill a gaping void in the market. Acting independently of Boston’s major healthcare organizations (HCOs), also gives the project a bit more leeway and a bit less risk aversion.

Above all, since the mobile health market has exploded, no one has been watching the watchmen –and it’s high time someone did so in a credible manner. Health apps are not games, and they should not be treated as such.

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[1] HealthTap published some rankings in a downloadable “top health apps” report and a series of blog posts. However, the report came out in early 2015, and the latest blog post went up in August 2015 – a veritable lifetime in the world of mobile apps.

[2] “Intended use” is an important distinction. A food diary app that claims to help users lose weight would be scored differently – and presumably more harshly – than an app that simply claims to be a food diary.

We came back from HIMSS and got right to work on the March Monthly Update for Chilmark Advisory Services subscribers. As we’ve reported in a previous post, HIMSS13 afforded enormous buzz and less enlightenment regarding the state of health IT, particularly the four key areas we see as essential to this industry making a true difference in patient care. In our March update, and the reports currently underway, Chilmark Research does the opposite: provide insight without buzz. Below are abstracts from this month’s update. To find out how you can receive the full update, send an email to: info at chilmarkresearch dot com

Public vs. Private Oversight of Mobile Health
John Moore III

mHealth, known for rapid innovation and iteration, has a tendency to buck at the snail’s pace of FDA regulation. Last month, during a series of hearings considering whether smartphones and tablets with medical apps qualify as medical devices and thus require FDA approval, many charged the FDA with stifling innovation. After all, how many developers or investors want to sink resources into an industry that will be regulated in ways that have yet to be determined?

Enter Happtique and its Health App Certification Program. Happtique intends to complement the work of the FDA, and has introduced a set of standards for health apps that fall into the grey area between apps that are clearly medical and those with a clear consumer focus. This could herald a new age of credibility for mHealth. However, as both regulator and marketplace for many of the apps that it regulates, Happtique could end up in a very sticky situation. They will need to tread carefully to maintain their objectivity in both certifying apps while at the same time providing a marketplace for mHealth apps.

The March Toward Better Patient Engagement
Naveen Rao

The open question in health IT these days is whether patient engagement will gain traction or if it will suffer the same fate as PHRs. One thing is certain; healthcare needs far better patient engagement methods, processes and techniques than what one finds today as most current efforts in engagement have very little to do with helping a patient manage a condition. Time and again in our discussions with healthcare institutions of all sizes we find the same scenario being played out – engagement today is focused on building patient/customer loyalty to the institution – they are simply no more than marketing efforts.

Stage 2 meaningful use is requiring a deeper level of patient access to their records via view, download and transmit requirements and there is even a requirement for some email messaging between provider and patient. But there is a bigger issue at play, payment reform wherein providers will be taking on more risk for the patient populations they manage. Without deeper engagement with the patient regarding a chronic disease, providers will struggle with these new payment risk models.

Several related markets, such as telemonitoring and wearable tech are taking off. Chilmark analyst Naveen Rao spent near-exclusive attention to the patient-engagement tracks, vendors, and sessions at HIMSS13. In his article for the March update, Naveen identifies three factors that will define if and how well the patient-engagement market will stay afloat in the coming years.

CommonWell Alliance Intends to Tackle Interop
John Moore

The announcement of CommonWell Health Alliance was likely the biggest story to come out of HIMSS (Allscripts acquiring longtime HIE partner dbMotion may have been a close second). The group’s stated purpose is to enable interoperability across the five founding members’ EHRs. For starters at least, this includes: Allscripts, athenahealth, Cerner, Greenway, and McKesson’s RelayHealth division. In its simplest form, CommonWell will establish a set of standards and services that enable query-based health information sharing in a heterogeneous EHR environment.

Part of the challenge with interoperability within a community of heterogeneous EHRs is that standards are useless when it comes to things like patient matching, consent management, or locating records, all of which are fundamental to interoperability and all of which require standardized services model. CommonWell founders know this and have plans to address it. The greatest challenge facing CommonWell, however, may be the market itself as adoption of HIE tech within the ambulatory sector remains a challenge.

Each month, subscribers to the Chilmark Advisory Services (CAS) receive an update of our research on the most transformative trends in the healthcare IT sector. Exclusive to CAS subscribers, monthly updates are part of the continuous feed of information and analysis we generate to keep subscribers on top of the rapid-fire changes in this market.