The implementation of Open APIs in the UK health system

Patient care is becoming increasingly fragmented between different domains and organisations, as care becomes more complex. Open APIs are being welcomed as a possible saviour of health IT in the UK, a way to open up the market to innovation and to free patient data from their current silos in pursuit of more integrated care. The aim is welcomed but successful delivery is complex. Matt Murphy, managing director of EMIS Health, describes how quality assurance and safeguards are essential to protect critical health systems, and that suppliers must be allowed to influence the process.

The UK’s NHS is leading a digital revolution - with the government urging rapid progress towards the delivery of integrated electronic records to support patient care across every health and social care setting. Smart central use of pump prime funding is facilitating innovative technology to support the new models of care that are being test-driven across the NHS to improve the transfer of care between different healthcare settings. Behind this worthy healthcare goal lies a technical challenge: how to increase interoperability between the multiplicity of software systems that serve this huge and complex health service. But it is achievable.

Open Application Programming Interfaces (Open APIs) are one of the key mechanisms that the national bodies - NHS England and the NHS Health and Social Care Information Centre (HSCIC) - want to use to facilitate shared working, alongside common technical standards, a new approach to information governance and a patient’s unique NHS number.

Open APIs are attractive - stimulating more product innovation and more integrated patient care - but there are complex factors to consider to ensure their successful implementation. In this article, I will share some thoughts and experiences as a leader in a company that has been at the forefront of eHealth interoperability for more than 20 years.

Why interoperability matters

NHS England chief executive Simon Stevens wants to reshape the UK health service so its focus is on the patient, not individual clinical services or organisations. He also wants technology to play its part in delivering the £22 billion in efficiency savings required in the service within the next five years. New models of delivering healthcare are necessary to achieve this level of efficiency, and technology must be an enabler not a barrier to this.

Interoperability of software systems is central to supporting these strategic NHS goals. Implemented effectively, Open APIs will give clinicians the holistic view of a patient that they need in real-time, captured by different systems at different points in the patient journey. Implemented responsibly, patient consent will drive the process to make sure that appropriate data is shared between healthcare professionals when they need it.

Sharing information has proven to reduce duplication of effort and improve the efficiency of the service by giving clinicians the information they need rather than a partial view based on their own specialism. For example, a project that enables access to patients’ GP records within a hospital based urgent care centre in London is reducing pressure on the local accident and emergency department.

“50% of patients presenting at accident and emergency are first seen by the GP-staffed service, who can access the patient’s medical record to advise on treatment. Only 10% of patients assessed are then sent on to the main emergency department.”

Matt Murphy, managing director, EMIS Health

Clinicians say that shared information means they are ordering fewer blood tests and X- rays than colleagues at other hospitals. This is an improvement in patient experience and efficiency through sharing records.

Different clinicians do have different needs from their clinical IT systems, which is why a single system can rarely be the solution. The clinical information needs of an orthopaedic surgeon, as an example, are very different from those of a family doctor. As well as their obviously differing roles, they use different healthcare terminology and clinical codes which need to be reconciled to create meaningful information, particularly when patients are handed over from one domain to another.

The solution, then, is to provide the best systems for different clinical settings, and to find a way for them to talk to each other. In a hospital environment, this is commonly done via a portal and/or a trust integration engine. This is a relatively mature market in UK healthcare for acute trusts, as these large complex organisations have to maintain multiple diagnostic and operational systems, serving very specific requirements. For these organisations, middleware is often the best approach to integrate delivery across departments and for visibility of pan-organisation performance. However, in the less complex out-of-hospital digital landscape, the approach is still evolving - now at a significant pace and with national NHS backing.

The appeal of Open APIs

A commitment to Open APIs is now a requirement for any IT supplier bidding for work via frameworks such as the GP Systems of Choice (GPSOC) or the LPP Community, Children’s and Mental Health Framework. This is also the case for central funding programmes like the Prime Minister’s Challenge Fund or the Integrated Digital Care Fund, which has awarded £240 million for innovative health tech projects in the last two years.

It is easy to understand the appeal. For government, Open APIs encourage innovation and new ideas, as well as freeing information from silos and delivering more integrated patient care. Quite rightly, NHS England also wants them to reduce ‘vendor lock-in,’ where NHS customers are restricted in the care they can provide because they are using closed systems that cannot or will not share information.

In response to this need, software suppliers must be mature and confident enough to embrace interoperability, as the benefits to patients are obvious. Above all, suppliers must work hard (as advisors, partners and implementers) to ensure that the software is never the reason why healthcare can’t be integrated.

The challenge of Open APIs

Healthcare is a unique arena for information technology - any mistake can directly impact patient care and potentially cause harm. This is where we need to ‘ground’ our vision for Open APIs, ensuring it faces up to the practical challenges. Information governance, safety, technical reliability and quality are fundamental principles - not optional. A bright product idea must be robustly product-tested and compliant with information governance guidelines before it can be plugged into frontline healthcare software. ‘Bright’ can quite quickly become ‘reckless’ or ‘irresponsible’ the moment frontline clinical care is compromised.

Imagine a scenario where a third- party application that hasn’t been quality-assured, compromises the performance of the patient records system of a major software supplier. For the clinical user, it could mean an inability to access the appropriate information relating to a patient. For the supplier, there would be damaged confidence amongst users and financial penalties due to loss of service. But most importantly, within hours, this could affect the care of millions of patients.

But these challenges mustn’t prevent innovation in healthcare technology. Software suppliers and national bodies must work together to ensure that innovation captures the headlines - not safety, performance or governance risks.

Making interoperability work

So what is the solution? In my view, government can work in partnership with the market rather than mandating a fixed approach. It is for government to set out its vision and define the technical and governance standards necessary to ensure consistency (in this case, for system interoperability) but not dictate software specifications.

“In a blossoming technology market, suppliers are best placed to work out ‘how’ to deliver technical outcomes within a standards-based framework.”

Matt Murphy, managing director, EMIS Health

Encouragingly, NHS England and the HSCIC are now working closely with leading software suppliers to create this exact collaborative approach.

Equally, software suppliers working in partnership is an important dynamic in a thriving innovative market. There are many examples of existing partnerships between large and small providers in the UK healthcare market that show what can be achieved. EMIS Health, for example, currently partners with over 60 specialist software providers in one area of healthcare alone (primary care) to offer advanced and complementary functionality tailored to local needs.

Some of these partners are two and three-person businesses, often founded by working clinicians. Both sides bring valuable expertise to the table, but the role of the larger supplier is to ensure full quality control, making sure the interfaces between the software are stable and reliable. In EMIS Health, we have started to take responsibility for software deployment, hosting, training, and customer support for smaller specialist software partners who want our help - ensuring safe, sustained delivery at scale.

These partnerships are delivering innovation in healthcare IT using Open APIs as the technological glue - implemented in a controlled and responsible manner. For me, this is the route to delivering greater interoperability in a healthcare software market, where innovative suppliers and visionaries in the NHS work in tandem to support longer and healthier lives for patients.

The original article appeared in the August issue of eHealth Law & Policy.