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July/August 2021

HIT Happenings: How APIs Help Deliver Better Outcomes
By Gautam M. “G” Shah
For The Record
Vol. 33 No. 4 P. 30

The COVID-19 pandemic disrupted the economy and dramatically highlighted many of the gaps in the US health care system. And while the industry rallied to provide care, the weaknesses in public health, care coordination, data interoperability, and technical infrastructure became ever more evident. The gaps, unfortunately, are still there.

However, there is good news on the horizon. As other industries have embraced digital transformation, so too can health care by connecting data and systems across and between different parties—patients, insurance companies, and care providers—using application programming interfaces (APIs). Indeed, an API-first approach helps create transparency, ease of use, and efficiency for all stakeholders in the health care ecosystem.

The Roundabout
For example, let’s say you are one of the 45% of Americans who has one or more chronic diseases. You need to see your physician because you are experiencing a health issue. You visit the physician’s website and see that she, as a result of COVID-19, now offers telehealth appointments. You log into the patient portal to book an appointment. You’ve now visited two systems.

Before the visit, the doctor’s staff checks your eligibility. At the same time, you decide to visit the insurance company’s website to check on copays and your deductible balance to determine the out-of-pocket expenses. In this new world of highly consumerized health care, you visit the provider’s portal again to provide medication history and insurance information. You’ve added three more system visits, for a total of five.

During the visit, your doctor prescribes medication and asks you to follow up with her in a week to check on the drug’s effectiveness. The practice’s system automatically sends the prescription to the pharmacy. You visit the portal again to make the follow-up appointment. Before driving to get the prescription, you check drug costs and pharmacy benefits. That’s three more systems, some the same as before, for a total of eight visits.

The information inputted into each of the websites is invisible to the other systems. There’s no easy way to get those data from one site to another. There’s no export function. In essence, the EHR and the other systems are disconnected.

This is precisely what APIs can change. By enabling data interoperability with standards-based interactions, APIs help provide a more connected health care experience, empowering patients and providers with the health information they need and want.

APIs break down system silos. They help create a more holistic patient experience by tying together the interactions and data needed to find a provider, assess available coverage, schedule appointments, view and manage labs and prescriptions, review care requirements, and manage billing and payment.

Looking for Acceptance
Unfortunately, the acceptance of APIs throughout the industry has yet to become universal. According to “Wired for Transformation: The State of Healthcare APIs,” a survey commissioned by Change Healthcare, less than 1 in 4 health care companies use or produce APIs at a sufficient scale to realize their full benefits.

That’s about to change. In the study, 9 of 10 executives said that APIs are either important or mission-critical to their operations. That may be why the majority of payers, providers, and health care tech companies surveyed in the study expect that spending on APIs will increase this year.

Of course, APIs must be designed to meet robust security and privacy requirements and accepted industry standards. They must be delivered in a manner that promotes trust, adoption, and use.

There are plenty of incentives, including the Centers for Medicare & Medicaid Services’ (CMS) requirement that payers make health care information available when a consumer requests that information, as well as the information blocking provisions featured in the 21st Century Cures Act. These requirements are tailor-made for APIs to connect disparate systems.

No industry sector can be left behind. Currently, far more providers use APIs at scale than do payers or health care vendors. The race to implement and use APIs may turn into a head-to-head competition among all players as CMS enforcement dates for data interoperability approach. Payers will need to act fast to catch up.

Fortunately, API use in health care is escalating for all stakeholders. The proportion of API use among payers, providers, and HIT vendors will become more or less equal by 2023, according to the study. By then, payers (61%), providers (67%), and HIT vendors (51%) expect to be majority mature in their use of APIs.

All Together Now
The services linked by APIs are crucial throughout the industry, ranging from eligibility and enrollment to claims adjudication, patient health information, and provider or consumer payments. Those who effectively adopt the use of APIs will gain a competitive edge. Those who don’t will be left behind while early adopters will gain market share.

API-enabled connectivity has been present—and critical—for years in other industries. Ride sharing? Booking trips? Buying kitchenware? Numerous industries use APIs that combine texting, phone calls, phone application protocols, communication stacks, maps, geographic positioning systems, and payment systems into one seamless experience.

That same degree of connectivity can and should be available in health care, whether that’s giving patients access to their own data (a right under HIPAA), creating better processes for patients to interact with payers and providers, or providers interacting with payers.

Health care needs to make data usable by providing access, an easy method to input information, the means to make financial transactions, and a way to enhance the user experience. APIs are key to providing that access.

Just as the modern digital economy cannot exist without APIs, health care cannot modernize without APIs. These tools will become the connective tissue between systems, driving connectivity, access, and transparency.

Indeed, APIs help the industry address the following four key trends:

• the consumerization of health care;
• a means of complying with regulations and laws, including CMS interoperability rules and the Cures Act information blocking rules;
• the transition to value-based care; and
• the growth of scalable, accessible, cloud-based technologies.

HIT leaders need to embrace and accelerate the availability of APIs as the vehicle of that transformation. The first step is developing a comprehensive portfolio of APIs that make critical data points accessible across the health care journey. The second step is to treat APIs as fully fledged products, making them secure, performant, scalable, and trustworthy. The third step is making APIs easily adoptable and broadly usable.

To advance innovation and ensure regulatory compliance, the industry must escalate its embrace of APIs. Greater API adoption not only stands to close the workflow gaps that were so harshly highlighted by the COVID-19 pandemic but also holds the added promise of accelerating the digital transformation of the entire industry.

— Gautam M. “G” Shah is vice president of platform and marketplace with Change Healthcare.