Sit, walk, or run, but don’t wobble – Zen proverb
In the context of the introductory proverb, sitting is a metaphor for contemplation and reflection prior to action. The need for innovation in healthcare is well known. The sheer prevalence of the word in provincial health strategies is an indication that governments have been contemplating the need for innovation for quite some time. Now that the ‘sitting’ is done, what can governments and arms-length agencies do to walk or run towards innovation while avoiding the pitfalls of wobbling?
Governmental organizations often lack the culture and support to take risks, be creative, and take new products or services to market. While innovation from within may be difficult, these same organizations are uniquely positioned to support open innovation; the idea that innovation can come from outside the organization while still helping the organization achieve its strategic goals.
There are four technological trends that governments can invest in to “walk” towards open innovation: open architecture, open data, application programming interfaces (APIs), and, substitutable apps.
Open architecture is essentially the design of systems – such as jurisdictional EHRs and their various sub components – to be vendor independent, non proprietary, and use popular standards1. One of the goals of open architecture is to make it easy for users to swap components or add new ones to extend the useful life, functionality, interoperability, and overall value provided to the organization and its stakeholders.
In simpler terms, open architecture helps organizations create the technological platform that supports innovation by facilitating external stakeholders to build products that consume the organization’s services and data. A full examination of open architecture principles and methodologies will be discussed in a future article, but for now it’s sufficient to think of it as a purposeful way of designing IT systems so that organizational data and services can be exposed to external users who want to innovate.
Open Data is “data that can be freely used, shared and built on by anyone, anywhere, for any purpose.”2 The good news is that all levels of government from municipal to federal have published catalogues of their open data to stimulate adoption.
Open data is an easy first step governments can take towards open innovation. For example, an app developer can combine open data
on surgical wait times for different hospitals with hospital location data to create apps that facilitate well-informed referral decisions. For example, a patient might be willing to travel farther to a hospital with a lower wait time for a surgery. Or what about a consumer app that combines that same data with surgical outcomes data and “rate your hospital” data? A patient might make an entirely different decision about where and when they’d like to be treated.
Microservices and APIs
A lot of Open Data is provided as spreadsheets and other static formats. Opening the data really requires application programming interfaces (APIs), common ways of providing the data through microservices for use in other apps.
Google, Sales Force, and Amazon are the often cited case studies on the impact companies can have by exposing microservices through APIs. Purposefully exposing microservices allows people outside of the organization to figure out the best ways to combine them into a better user experience that ultimately fulfills unmet needs of consumers.
Government organizations have tons of data that could be used to spur innovative products and services. Something as small as a code set for lab test names used in a provincial Lab Information System could be exposed as a microservice in an API so that anyone maintaining a community lab information system or EMR can integrate their code sets and sync updates.
We’re fortunate in Canada to have numerous provincial and national organizations dedicated to the creation of health indicators. Exposing health indicators through APIs passes on the value an organization already created by defining statistical methodologies and crunching raw data, while simultaneously helping the organization achieve the goal of getting the statistics into the hands of decision makers. For example, APIs that expose quality of care statistics could be used by clinical and consumer apps to compare individuals against national averages, and hopefully lead to better decisions by physicians and patients alike.
When people see the word “app” – they often think of small applications designed to do a couple of things really well and running on a mobile device. In a broader sense an app is just a piece of software and the term equally applies to standalone software running on desktops or in running in larger systems such as EMRs and HIS’. The term substitutable simply means the same app can run in different systems with minimal customization.
EMRs and HIS’ are ideal candidates for supporting substitutable apps. They have the raw data and are at the point of service where treatment decisions have the biggest impact on patient outcomes. Given the diversity of the different medical disciplines, specialties, and populations they serve, it is almost impossible for a single HIS or EMR vendor to provide a product with the functionality to meet the needs of all users, and to rapidly change as users’ needs evolve.
The SMART on FHIR specifications describe common APIs that allow people to create apps that can run in different vendors’ products. SMART on FHIR relies on “Open standards for healthcare data, authorization, and UI integration.”
Using SMART on FHIR, people can build apps that do one thing really well and use data already held in HIS’ and EMRs. SMART on FHIR apps are ideal for providing better ways of visualizing and comparing data, performing physician’s routine but complex calculations, or pulling in comparative data from outside sources. I highly encourage readers to check out the SMART on FHIR app gallery here: https://gallery.smarthealthit.org. The gallery already has apps that help physicians assess and explain a patient’s 10- year cardiac risk profile using interactive and simple visualizations, showing patients in real time how lifestyle changes can lower their risks. Some apps help predict patient medication adherence based on prescription and fill history, while others alert physicians to new best practices based on matching industry journal information to ICD-10 codes in patient records.
Time to Run
App developers seeking to innovate in the healthcare domain in Canada are challenged by variability. There are numerous jurisdictions responsible for funding and delivering care, and they all have different systems and data. Apps that need to connect to jurisdictional HIALs will encounter significant differences in basic protocols for transport layer security, authentication, and authorization, with even greater variation in how EHR services are designed to provide clinical data. Similarly, the availability of open data is different across jurisdictions, and within similar data there is variability in the time period the data covers and how the data is provided.
Designing apps to run in EMRs and HIS’ are further stymied by the tremendous variability in the products deployed in the different jurisdictions – covering a gamut of vendors, versions, and deployment types (e.g. local vs cloud).
Running towards open innovation requires governments across Canada to collaborate on the actions they can take to remove variation across the jurisdictions, invest in technologies that support open innovation, and promote their IT assets to app developers.
Government commitments to innovation and trends in releasing open data are encouraging. But as Ernest Hemmingway said, “never confuse motion with action”. Simply releasing open data sets is not enough. They need to be promoted, maintained and coordinated across Canada so that a wait times app built in Nova Scotia can work in BC. The same is true of all the other technologies discussed in this article.
To avoid wobbling, there needs to be recognition that open innovation is a national goal, that requires coordinated investments by the jurisdictions to achieve. If done right, governments can shed the burden of being the producers of innovative products or services, and instead be the facilitators of open innovation.