Although there has been widespread optimism expressed about the potential of application programming interfaces (APIs) and the FHIR (Fast Healthcare Interoperability Resources) standard, it may be a while before deployments are widespread. But that doesn’t mean they aren’t starting to find their way into provider organizations.
Last week I had the chance to interview Louis Krenn, M.D., chief medical information officer at five-hospital CoxHealth in Springfield, Mo. Cox’s hospitals use Cerner’s EHR platform and Krenn is leading the transition of its ambulatory practices from GE Centricity to Cerner.
One of the advantages of the switch is the ability to easily deploy SMART on FHIR apps, which run on top of the EHR. As Cerner notes, physicians can access these “pluggable apps” directly within their workflow to more easily visualize, interact and transmit health data.
The first example Krenn mentioned is a clinical decision support tool called VisualDx. With an initial focus on dermatology, VisualDx allows physicians to build a differential to evaluate the possibilities, compare variations, and improve diagnostic accuracy at the point of care.
“Especially from a primary care perspective VisualDx is appealing because dermatology is a large need, but it is something a lot of primary care doctors don’t have a lot of experience with,” Krenn said. So having that point-of-care tool available is important to us. We had a contract with VisualDx for a while before we instituted the SMART on FHIR piece, so we were familiar with the company and the technology.” He liked the tool, but you had to launch out to a separate website and put in user name and password, or you had to pull out a smartphone to use the mobile application. Now the app is embedded within the clinical record. “I am already logged into the application. I click another tab in my EMR, and it passes through credentials. I don’t have to log in to anything,” he said.
“SMART of FHIR allows the app to gather the clinical information about the patient to refine your search much faster. It sends how old the patient is, male or female, medications, allergies, anything on the problem list, and begins to refine your differential before you even ask,” he said. “When I go to the VisualDx tab in my Cerner record, as it loads, immediately it is already passing through to VisualDx that information. When I start to give the application additional clinical information, it is already taking into consideration the context of that patient. I could take the time to tell the application all this information manually, but that is going to take me a lot longer to get to my diagnosis. If we are using this at the point of care in front of the patient, we want to be as efficient as we can.”
VisualDx has been branching out beyond dermatology. You could search for lung cancer and it will give you radiologic images of what lung cancer might look like on a scan, he added.
Krenn said he is actively looking at other apps in the SMART on FHIR app gallery, including a bilirubin risk chart app and a pediatric growth chart app. “We are trying to negotiate for a license to [clinical decision support tool] UptoDate and they are interested in embedding with us through SMART on FHIR as well,” he added.
Krenn believes the “app store” model for modular improvements to EHRs is very promising. “Everybody has a smartphone in their pocket and everyone understands apps and add-ons. Even the layperson has heard the term API at least once and understands the concept,” he said. The ability to look in a store and find out what is available and see a quick video demonstration of it is definitely appealing since this is relying on folks external to your core EMR to provide you with this information. By having Cerner or another vendor create an app story similar to what Google and Apple have done is definitely beneficial.”
Krenn has been pleasantly surprised at the uptake of VisualDx now that it is embedded in the EHR. "We have seen increased usage based on having it conveniently available, and the usage has been sustained. On average, we have about 20 users per day, and 300 unique users per month, so it's not the same 20 users going back every day.”
“When I go to the VisualDx tab in my Cerner record, as it loads, immediately it is already passing through to VisualDx that information. When I start to give the application additional clinical information, it is already taking into consideration the context of that patient."