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How Will Amazon, Google, Microsoft Impact EHR Interoperability, FHIR?

Amazon, Google, Microsoft, and others could significantly impact how EHR vendors approach the FHIR API standard and interoperability.

EHR interoperability

Source: Thinkstock

By Elizabeth O'Dowd

- Earlier this month Amazon, Google, Microsoft, IBM, Oracle, and Salesforce announced their intent to jointly commit “to removing barriers for the adoption of technologies for healthcare interoperability, particularly those that are enabled through the cloud and AI.”

This pledge could reshape how healthcare organizations share data and interact with interoperability standards, according to Redox Senior Developer Nick Hatt.

“The biggest take away from this pledge for me is that all these tech companies are going to level-set and agree to not compete on integration,” Hatt told HITInfrastructure.com. “They're all trying to sell different kinds of AI and cloud services to help healthcare systems.”

Integration in the healthcare space could become a differentiator for any one of these tech giants. If this is the case,  they will not be able to sell their AI and cloud services to healthcare organizations and more data silos will be created.

“You can compare it to the web standard world,” said Hatt. “Microsoft, Google, and Apple all make competing browsers for market share in the browser space, but they can all agree on HTML and they can all agree on JavaScript. These companies participate in those standards, but they want to compete on the implementation and not on the standard.”

READ MORE: Why Application Programming Interfaces Are Key for Healthcare

One of the most significant changes this pledge could potentially bring is how these companies are going to interact and integrate with EHR vendors.

“The adoption of FHIR by EHR vendors has been historically slow and spotty,” Hatt explained. “You still get variations between how Cerner does FHIR and how Epic does FHIR.”

Hatt believes that the differences in how different EHR vendors work with FHIR will create a potential clashing point.

“These cloud companies want one standard interface, and they want FHIR to be consistent across all EHR vendors,” said Hatt. “All the vendors in the pledge do roughly the same thing in terms of what they support. However, that’s not where EHR vendor strength is right now.”

Generally, EHR vendors should be considering how their products will integrate with cloud. For example, if a provider purchases an AI technology supported by a major cloud vendor, they may have problems integrating the AI technology with their EHR.

READ MORE: APIs Are the “Missing Piece” for Healthcare App Interoperability  

Most of the EHR market is made up of EHR solutions that are deployed and hosted on-premises by the provider, according to Hatt.

“When it comes to EHR vendors that are cloud-based, they can deploy the FHIR API rapidly,” Hatt explained. “But the EHR vendor already has pretty robust APIs so when they develop a FHIR API it's almost like they're taking a step backward.”

“Each one of those cloud APIs is proprietary,” he continued. “The Athena API is totally different from the Allscripts API. FHIR does have a higher level of standardization, but as a developer you want to get the most robust information. If the EHR vendor’s API has extra fields you care about but they're not in the FHIR version, you're going to use the proprietary API.”

At this point, there’s no real government incentive for EHR vendors to use FHIR. Without that, EHR vendors are waiting for providers to buy Google AI and have Google want to use FHIR. Hatt believes that the industry is still a long way away from this kind of sale happening.

“There's still this cost-benefit analysis for these EHR vendors,” said Hatt. “Do they really need to do FHIR if nobody's going to use it?”

READ MORE: ONC Promotes Open APIs to Solve Interoperability Challenges

There’s also the question of how these large cloud vendors are going to deal with the strict standards of the healthcare world.

“I think the healthcare market is much more fragmented than what these companies are used to,” said Hatt. “It's easy for Google, Mozilla, and a consulting company to sit down and write a spec for a new internet protocol. But when it comes to having Google, Epic, Cerner, and a whole bunch of smaller EHR vendors sit down and write a spec, the process might be a little slower.”

“These major cloud vendors’ activities have been mostly non-existent in the healthcare standards world,” Hatt explained. “It will be interesting to see what sort of resources they throw into it. We'll see who's contributing. They're essentially calling out EHR vendors for their speed, and so it's time for the EHR vendors to start making progress on this stuff.”

This suggests that EHR vendors will need to be better about interoperability because they will need to work with these six companies at some point and they are committed to using the same standard. Even though the health system owns the data, the EHR vendor holds the reins on the data so the vendor will be the one building out these APIs.

Hatt also wonders if things don’t go the way these six companies want in terms of interoperability standards, what are they going to do?

The companies don’t have a lot of leverage beyond telling an EHR vendor that their product isn’t working with them. At that point, the provider has already invested in its EHR so there isn’t much the cloud vendor can do.

Hatt speculates that the cloud vendors could cite the pending 21st Century Jurors Act legislation around EHR policies.

“One of the policies is generally referred to as data-blocking,” Hatt explained. “It's a very nebulous term and we’re waiting to hear what the government actually thinks it is. But we could start to see a little bit less cooperation than the tone the letters strikes.”

“For example, if one of the cloud companies gets frustrated with working with a particular EHR vendor, it might try to use the government as a tool to either punish that particular vendor, or somehow remedy that situation.”

It’s hard to predict what the legislation will contain, but providers and vendors should keep an eye on the incentives for health systems to use interoperable software because it could affect how cooperative these organizations will be.

Regardless of pending legislation, the agreement made by Amazon, Google, Microsoft, IBM, Oracle, and Salesforce is an interesting development for the future of healthcare IT.

“It will be quite interesting to watch,” said Hatt. “The amount of developers at these companies is really overwhelming. If Google wanted to dominate HL7 and correct the problems holding down FHIR, it could potentially throw money at the problem and make it go away. We'll see if the consensus holds up, and we'll see if the six companies really do value interoperability and stick to this pledge.”

“It’s easy to cheat on integration, but nobody wants that,” Hatt concluded. “As a patient I don't want that, as a health system I don’t want that, and as a major cloud provider I don't want other people doing that. It's really quite fascinating from a strategy perspective, so we'll be keeping our eyes on it.”

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