Health 2.0 EMR API report 2018

2018 Data, including updates from the 2016 survey
EMR-API Survey Results
Report Generated by:

Generated Report for:
Q1: How vital is it for your product/service to integrate with an EMR?
79%
19%
2%
Vital Nice to have Optional Unncessary
Total Respondents: 103
2
Small health tech companies really
care about integrating with EMRs

Q2: How significant do you think the change in sentiment from mainstream EMR
vendors has been around allowing easier API-access and other forms of data access for
third party tool integration over the last 2 years?
Total Responses: 103
3%
11%
63%
23%
The big EMR vendors are getting better….
3
Significant Improvement
Modest Improvement
No Change
Situation Got Worse

Q3: How significant do you think the change in sentiment from health care providers
has been around allowing easier API-access and other forms of data access for third party
tool integration over the last 2 years?
1%
22%
54%
23%
….Providers need to catch up
4
Significant Improvement
Modest Improvement
No Change
Situation Got Worse

Q4: Are you investigating blockchain technologies as another method for data
storage, integration, or anything else?
7%
50%
38%
5%
Blockchain—Getting beyond a buzzword?
5
Yes, we’re actively using them
Yes, we’re investigating
No, not yet
N/A

Q5: What have your interactions been with the Carin Alliance?
80%
5%
11%
4%
Aneesh/Ryan? Get to work guys!
6
Actively working with Carin
Alliance
Investigating working with
Carin Alliance
Decided not to work with
Carin Alliance
What is the Carin Alliance?

Do you have any general comments on the progress towards data access?
7
Most respondents feel data access still needs
improvement…
“There still are multiple barriers. No progress towards writing data back into EHRs via API.
Large upfront fee or revenue share requirements by EHR vendors.”
“Frankly it's a mess. Epic is the only company we need access to and their support to external
companies is a joke. They rarely respond to requests for information/help and when they do they tell
us that as a startup we don't have the rights and size to integrate with their platform. It's a dreadful
state of affairs. I suspect they do this to steal the ideas of startups so they can integrate the ideas into
their products. Thus, resulting in zero need for products from startups.”
“Surveillance capitalism and regulatory capture still rule the day. Patient data is worth a lot of
money and virtually no one is wanting to have real transparency on how it's used to manipulate
prices or "create" intellectual property.”
“Yes - most vendors are unresponsive and do not see the value in integrating with third parties,
which stymies our growth. “
“Still a lot of talk, obvious value to be had but limited actual progress.”

8
…but some feel like data access is getting better despite the
barriers
Do you have any general comments on the progress towards data access?
“Both Cerner and Epic have been very accommodating. Their pricing strategies are
not set in stone and they seem to be trailing different options.”
“It's an exciting time to be involved in data access and interoperability.”
“I have seen a change, I feel like my clients do not have to beg as much to get a
chance to talk about why they need the EMR to work with us. But the barriers still
exist.”
“Technical progress on standards like FHIR and SMART have been great. Business
progress has been slow (e.g. app store business models).”
“It is moving in a better direction, however, the cost involved is too much in some
cases which make it tough to integrate.”

Q6: Has your company attempted an integration with an EMR vendor?
85%
15% No. We haven’t.
Yes! We’ve integrated.
Yes: 88
No: 15
9
Most respondents know of what they speak

Q7: Please select one of the following that best describes the extent of your integration attempt(s).
Total Respondents: 2018: 87/ 2016: 73
11% 36% 30%
23%
Yes!We’veintegratedNo.Wehaven’t
11
Read and write
Extracting data from the
EMR and inserting data
back into the EMR (i.e.
read and write)
Read
Extracting data from
the EMR for a
proprietary
application (i.e. read)
Read, write and
change
Extract data, insert data
back into the EMR, and
make a change within the
vendor system (i.e. read,
write, and change)
Manipulate
Bring in your own external
data & combine it with data
generated by vendor system,
manipulate/analyze it and
make a change
8% 33% 27% 32%
2018
2016
Most integration remains read & write with
some slight changes
Note: This question was based on a suggestion from Lyle Berkowitz MD

Do you have any comments about your ability to write to an EHR and the consistency of that experience
across various EHR integrations (e.g. have you resorted to a PDF as the lowest common denominator)?
12
“We have worked with Athenahealth in writing our data back to the EMR. Since we leverage
their API platform we have only resorted to sending PDFs for consents and missing API writes.
The experience has been good and bad. We have access to write to a lot of data in the EMR but we
often find many of the API endpoints are not tested completely so the development partner bears
the cost of testing the interface”
“Resorted to PDF as lowest common denominator, and that is even a challenge in some scenarios.”
“Unable. Epic doesn't even allow access to the data we want to access, let alone being able to
write data.”
“Very difficult. Athenahealth is the only one that makes it easy to write into the EHR”
“Most EMRs are not very open, so we use Redox except for AthenaHealth where we have direct
integration. We do use PDF as a lowest common denominator.”
Ability to write to an EHR differs by vendor, with
Athenahealth getting the most praise

Q8: How many integrations has your company attempted?
48% 17%
7% 3% 25%
20+
13
1-5 5-10 10-15 15-20
63% 18%
1%
3%
15%
2018
2016
Most companies have done more integrations since 2016

Q10: Were the majority of these integrations started before the end of 2015 or after January 2016?
14
16%
Before December
2015
84%
After January
2016
The pace has definitely picked up in the last 2 years

Q9: Which EMR vendors have you integrated with?
Note that respondents were able to select more than one vendor.
The mean number of integrations per respondent is 4, while the
median number of integrations is 3.
64% Respondents: 54
19% Respondents: 16
45% Respondents: 38
53% Respondents: 45
54%
Respondents: 46
27% Respondents: 23
20% Respondents: 17
29% Respondents: 25
29% Respondents: 25
15
Integrations reflect Epic’s dominant position

Q11: How did you access the data?
40% 39%
72%
31%
7%
24% 25%
83%
19%
29%
21%
14%
25%
43% 12%
4%
19%
26%
25%
14%
38%
36%
53%
50%
10%
50%
6%
14%
6% 14% 12%
4%
13%
25%
16
Used Direct
or Other
Protocol
Used
Batch or
Non-API
Data
Exchange
Used 3rd
Party
Integration
Engine
Accessed
Vendor
API
Data access? Athenahealth & Allscripts’ APIs
lead the pack

Most growth for Cerner & Epic has been in using 3rd
party integrators. Well done, Redox!
17
72%
72%
83%
75%
39%
31%
40% 42%
14%
4%
4%
4%
21%
19%
19%
14%
16%
10%
17%
25%
25%
26%
19%
8% 4%
14%
25% 19%
29%
4% 6%
2018 2018 2018 20182016 2016 2016 2016
Used Direct
or Other
Protocol
Used
Batch or
Non-API
Data
Exchange
Used 3rd
Party
Integration
Engine
Accessed
Vendor
API
Data access method, the big 4 compared 2018-2016

But in reality, it’s not simple...
18
“For many vendors, it is a combination of
ways to get all the workflows we need (other
than Allscripts and Athenahealth). Epic still
requires a mix of API, HL7, direct message
and batches. Others are HL7 and direct.”

Q13: Was a large provider client necessary to engage
a vendor in a conversation about accessing data?
Respondents: 35 | No: 6 // Yes: 29 Respondents: 13 | No: 8 // Yes: 5
Respondents: 28 | No: 22 // Yes: 6
Respondents: 18 | No: 10 // Yes: 8 Respondents: 16| No: 7 // Yes: 9
83% 17%
69% 31%
21% 79%
50% 50%
57% 43%
44% 56%
38% 62%
23% 77%
56% 44%
NoYes
19
Want to integrate with Epic? Get a client.
Others getting more accessible.

Q14: Were there any terms in the contracting with the client or vendor that you found
troubling, e.g. that inhibited your ability to keep your intellectual property?
20
39%
61%
Yes: 21
No: 33
A big minority have trouble with EMR contract
terms…

And the finger is pointed at the usual suspects!
21
“High upfront cost in order to partner with EHR and get access to APIs”
“Epic asks for first born child and then some to participate. I hope they get a FTC lawsuit in the future.”
“The Epic App Orchard, which we still haven't been able to sign, has some brutal terms that give
our IP to Epic. Still trying to work through that.”
“Epic was tough about giving us access to CCD documents. Not super helpful during integration
implementation and wouldn't commit to any enhancement requests.”
“Epic wants to know the details of our technology. It is high proprietary information and I know
what Epic is up to, they want to take it for themselves.”
“Epic - App Orchard terms are very broad and unfriendly to "partner" vendors, and they were
not open to any negotiation of terms”
“Cerner has a lot of byzantine IP policies and refuses to publish API endpoints. Epic is much better.”
“Allscripts has a clause that many believe allows them to take anything running on a client's station.”
“Some third-party marketplace programs have very strict restrictions on non-compete. This
makes it very difficult to build a product without fear of being ejected from the App Store.”

Experiences and initial contacts vary
22
“Athena, Allscripts and now Epic have an application process and a workflow
you go through to get developed, tested, deployed. NextGen did a partner
agreement so we co-designed the integration to what they could handle. The
rest we had to figure it out on our own.”
“First contracted with the health system, got them on board, and then signed
Redox as an integration partner. Then, the health system contacted Epic.”
“We have several of these, typically the client is the initial contact, they then
contact the EMR vendor, then we then work through a series of meetings to
get the systems integrated”
“Mutual customer contacted us and set up meeting with integration team from
other vendor or hospital. Often multiple meetings to map out and work
through challenges.”
Please provide a general overview of the integration process. (i.e. who was your initial contact,
what sort of meetings were required, how did you ultimately reach an agreement etc.).

If you’ve integrated across multiple EMRs, does the process begin to get easier and where? Is the process easier
because you know what you’re doing or are economies of scale gained in regards to technical lift?
23
“The process only gets modestly easier. The elements that are defined by SMART on FHIR get
easier. But the variables of whether each vendor provides a decent test sandbox, how to write back
to the EHR, who does what during implementation -- These are the items that are really difficult
with the first integration with each EHR vendor. Then your second Cerner, second Epic, second
Sunrise, second Paragon implementations are indeed easier. And it's easier because we know
what we're doing, not writing the implementation guide for the first time!”
“It is easier with experience, but for most EMRs a large customer is required to get any
movement on the EMR side. For this reason we use Redox for much easier access, albeit at
the cost of a deeper integration into the EMR workflow.”
“Not necessarily because the problem is a business problem and not a technology problem”
“Yes, it gets easier and you start to see patterns. Also our own infrastructure is significantly
more sophisticated than it was two years ago.”
Most respondents say the process gets easier,
some disagree

Q15: Would you say vendors were generally supportive of your integration efforts?
Respondents: 36 | Yes: 16 // No: 20 Respondents: 12 | Yes: 7 // No: 5
Respondents: 27 | Yes: 24 // No: 3
44% 56%
61% 39%
38% 62%
36% 64%
47% 53%
58% 42%
50% 50%
YesNo
24
89% 11%
97%
3%
Some EMRs support the little guys,
others not so much.

25
In general, the big guys are becoming more supportive,
especially Cerner
44% 56% 61% 39%
89% 11% 97%
3%
2018
2018
2018
2018
37% 63% 31% 69%
77% 23% 75% 25%
2016
2016
2016
2016
Were vendors supportive? The big 4 compared 2018-2016

Q16: Was there a fee associated with accessing an EMR vendor API or other non-API
interfaces?
63% 37%
72% 28%
63% 37%
75% 25%
73% 27%
43% 57%
60% 40%
65% 35%
77% 23%
Free$
26
Majority of vendors still charge a fee,
most of the time

Q17: If you were charged a fee, did it most resemble:
27
36%
47%
15%
20%
40%
44%
33%
27%
50% 32%
40%
40%
20% 11%
77%
45%
14%
10%
40%
30%
20%
22%
33% 9% 18%
10%
10%
20% 22%
14%
9%5%
33%
Annual
License
Fee
Percent
Revenue
Share or
Other
Trans-
actional
Fee
Other
But the charge is moving to % of revenue

Q18: If there were fees associated with accessing a vendor API, how much do you estimate they totaled?
28
53% 24% 24%
$25,000- $50,000 > $50,000< $25,000
67% 33%
60% 10% 30%
60% 20% 20%
50% 17% 33%
67% 33%
50% 50%
73% 27%
63% 12% 25%
Most fees remain relatively modest

Q19: Overall, would you say EMR vendors helped or hindered the integration process?
Respondents: 32 | Helped: 12 // Hindered: 20 Respondents: 11 | Helped: 6 // Hindered: 5
Respondents: 27 | Helped: 21 // Hindered: 6
38% 62%
52% 48%
78% 22%
35% 65%
24% 76%
43% 57%
55% 45%
40% 60%
HelpedHindered
29
89%
11%
In general, the same two vendors remained
helpful outliers…

…and some have gotten worse
30
2018
2016
2018
2018
2018
2016
2016
2016
24% 76%
52% 48% 38% 62%
55% 45%
HelpedHindered
48% 52%
71% 29%60% 40%
47% 53%
Are EMR vendors helpful? Comparison 2018-2016

Program exists; easy to understand Program exists; enrolling somewhat complicated Non-existent programs; difficult to enroll
Partner programs: Still a huge gap!
17%
60%
23%
Respondents: 35 Respondents: 14 Respondents: 9
21%
79%
11%
33%56%
38%
38%
23% 18%
82%
72%
25%
3%
63%
27%
10%
44%
56%
22
100%

Partner Programs: your experience may vary!
32
“Cerner and Allscripts are a dream to work
with. eCW, GE & NextGen are good, but since
they have no official program, the business
relationship and terms are custom. Epic App
Orchard contract is unreasonable and Epic’s
test sandbox is not properly supported.”

Big 4 are becoming much better partners
33
63%
27%
10%
2018 2018
72%
25%
3%
Program exists; easy to understand Program exists; enrolling somewhat complicated Non-existent programs; difficult to enroll
38%
38%
23%
2018
17%
60%
23%
2018
15%
33%
52%
2016
43%
46%
11%
2016
43%
48%
9%
2016
13%
40%
47%
2016

API quality? Still Athenahealth & the rest
23
High technical quality, relatively easy to work with Not great, but workable Poorly designed APIs
34%
48%
17%
67%
33%
25%
50%
25%
24%
67%
9% 17%
17%
66%
85%
11%
4%
46%
42%
12%
80%
20%
50%50%

In general, the big 4’s APIs are getting better
35
2018 2018
2018 2018 2016
2016 2016
2016
85%
11%
4%
60%
32%
8%
34%
48%
17%
24%
67%
9%
46%
42%
12%
28%
48%
24%
27%
45%
27% 25%
67%
8%

Rest of the vendors’ APIs are getting better but
some, like Meditech, are getting worse
36
2018 2018
2018 2018 2016
2016 2016
2016
50%50%
80%
20%
67%
33%
18%
45%
36%
10%
40%
50%
23%
38%
38%
17%
17%
66%
25%
50%
25%
2018
17%
50%
33%
14%
71%
14%
2016

App Stores are getting real
33% Respondents: 18
50% 33%
19%39%
17%
24
Respondents: 21
Respondents: 9
Respondents: 10
Respondents: 27 Respondents: 18
None
Q22: Have you taken part in a vendor’s app store program?

Are the App stores worth it?
38
“Many of them are starting to roll out programs but most are very early. Love the App Store
concept for ease of use. Fees can be hefty.”
“Had to back out of Epic Orchard - agreement was too risky for the business. TBD on Cerner
and Athena - cost is high.”
“Epic: $5000/$15000/$30000 to join app orchard plus transaction costs. Very expensive.”
“The Athena and Allscripts App stores are great but they do not help in promoting us or with
acquiring clients”
“Athenahealth does offer the MDP program, but they do not adequately support it. The
company is resistant to working with us to market to their existing customers, and their large
account team actively worked against us giving customers inaccurate information.”
“As an earlier stage start up, having to pay 20% revenue share for a client clicking through to
us from a marketplace with virtually no sales support is high but necessary evil.”

Q23: Several of the major vendors, including Epic, Cerner, and Allscripts, have opened
their FHIR standards, but so far only about 20-30 providers have made them available.
Do you:
39
13% 22% 33% 32%
Have provider clients /
prospects who have
already made data
available via FHIR
Have provider
clients / prospects
who are telling you
they will take part
Find little interest in this
from your provider
clients / prospect
Not have any
experience with
this
Providers may be the biggest hurdle.

Who is to blame for creating a bottleneck around data
access? Providers or EMR Vendors…?
40
“EMR vendors are definitely creating a bottleneck around data access, even for their own
clients with sometimes obscene fees for something as simple as a flat-file report!”
“I still see EMR vendors as the major bottleneck in data access. Poorly defined
APIs, high cost of access, little to no support for developers. There are exceptions
(Allscripts and Athena), but this is generally the rule.”
“Providers very much want easier access to data. Usually have a complicated
bureaucracy within the hospital system to navigate to allow that.”
“It seems like Epic has the reins tight on their customers as well as startups like
mine from coming in and accessing the data to for financial gain with their
systems. Epic might like to give the impression of being open but in reality it's a
very murky and mysteriously dark world of affairs going on at Epic. It's really
disheartening.”
“Yes, certain vendors are a bottleneck around data access.”

…opinions are split.
41
“It always seems to be a chicken-egg scenario. Provider: ‘I would love it if you would integrate
with our EHR vendor’ -- Vendor: ‘I would be happy to integrate, when the provider makes me
do it’ and around and around we go. But things do seem to be getting better.”
“There are several functions that require data exchange that are on the edge of HIPAA
requirements that many EMRs and providers use as a reason they hide behind and use as
reasons not to leverage innovative technologies in the market today.”
“Not much has changed in this space since 2012. Some EHR vendors continue to be difficult to
work with and others are starting to loosen their grip a bit. Unfortunately, local hospital IT
shops continue to be afraid to allow access to data by third party vendors.”
“It's both. In most cases one points to the other.”
“Most of our clients have been very willing to open data access to 3rd party apps that bring
demonstrable value to their health system.”

Q24: How available would you say the FHIR standard is these days?
Total Responses: 54
13%
45%
34%
8%
And what about FHIR?
42
Available for Read, Write,
Update
Available for Read
Not Widely Available
Not Sure

Do you have any comments on what you’re seeing or would expect to see from
government / HHS / ONC in promoting or enforcing access to data via APIs?
43
“I would like to see the government push harder for interoperability. The EHR vendors got a
huge taxpayer funded windfall with Meaningful Use and they should be pushed to open up.”
“I would like to see government set the example and standards for open APIs in digital health
care that will allow for additional innovation and shared data."
“Not only access but enforcing some process-oriented goals such as timeline to access, sandbox
to try, etc”
“I would expect to see the government pushing EMRs to open up their platforms for innovative
companies like my own to come in and make exciting change to drive down costs and improve
quality of care. Then again, who knows with this trumped up government we have right now.”
Everyone hopes the government
pressures EMRs to open up

Q25: Have you integrated with Healthkit or other Apple platforms?
44
9%
Yes: 5
Of those who answered
“yes”, 40% indicated
the data they are using
via Healthkit was from
a traditional EMR or
other health provider
data source
91%
No: 48
40%
60%
Apple may be the future of EHRs. But not yet!

Q27: Apple Health requires that providers publish an open API that conforms to the
Argonaut Project implementation guide of the FHIR API. Have you connected to any
providers in a manner consistent with the method required by Apple?
Total Responses: 53
4%
96%
Yes No
…and Apple’s EMR API? Not yet either
45

Please describe why you haven’t integrated with an EMR.
0%
55%
36%
9%
47
Application does not need
integration to add value
Have attempted to integrate,
but process was too difficult
Other integration engine
means direct integration is
not necessary
Too Costly
Most who haven’t integrated are finding a way around it

48
41%
0%
7%
55%
21%
36%
48%
9%
Compared to 2016, integration engines are giving
vendors what they need
Application does not
need integration to
add value
Have attempted to
integrate, but process
was too difficult
Other integration
engine means direct
integration is not
necessary
Too Costly
2016
2016
2016
2016

Is there other medical data stored in an EMR that could enrich this application or
improve the user experience?
45% 55%
Yes No
49
Other data requested was:
• “Orders and scheduled procedures, filing documents to visit ID so that all documentation can be associated
with each encounter/appointment”
• “Images and genomes”
• “Lab data”
• “Provider Notes, Radiology Reports, Microbiology Results”
• “exact diagnostics (e.g. molecular tumor profiling)”
Some still want more data types…

Would the patient benefit from his/her professional care team receiving data from this
application via (or in combination with) the EMR?
100%
Yes No
50
But everyone thinks data will benefit their application

Are there other crucial functionalities that could be added via an EMR integration (i.e.
scheduling, notifications, messaging)?
82% 18%
Yes No
51
And would like to be able to exchange data with them.

Please include any other thoughts or comments you'd like to share on issues around or the general process of
integrating third party applications into EMR systems.
52
“Overall it's expensive. The most expensive part is troubleshooting the API. We've found
that more often than not, the API endpoints have issues. Finding those issues and
troubleshooting them is a very expensive task.”
“As a startup with limited capital I don't have the umph or clout I need with Epic to get
them motivated to help my company integrate with the Epic EMR. I sincerely hope all the
other companies with my same plight fill out this survey. Hopefully it can effect some
change in the industry. We need it.”
“We are very much at the mercy of the EHRs and lack of integration with EHRs is really
limiting our ability to get people to use our products”
“Nightmare, continues to worsen. Expensive. Big blocks to real innovation”
“Athena aside (and maybe Allscripts), the other EMR vendors are not 'open' despite the
activity they project with their involvement in projects like Argonaut and FHIR.”
In general, small tech companies are still not happy

54
Details on survey methodology
We ran this survey from Feb 26, 2018 to July 24, 2018. However all but 10 respondents took the
survey between late February and mid May. We continually advertised the survey and sent out
initiations to take it both via our own resources and with several partners. Given that hundreds of
small tech companies are now working with EMRs and we also had trouble getting responses in 2016
we can safely say that it’s hard to get them to respond to this type of survey.
The sample size of this survey was 103 verified respondents. We excluded 6 respondents from an
original 109. The excluded respondents were from Redox, Datica, Sansoro and Allscripts because they
are in the business of providing access to APIs. However, we have often used their comments.
103 verified respondents began the survey, but not all 103 completed the survey in its entirety. There
was significant drop off following question 10, which was the last question before respondents moved
on to the long set of questions involving specific vendors.
Where possible, we've presented the largest sample size of data for any given question, though we also
compared the larger sample size to the group of 64 respondents that completed the survey in full.
Overall, the smaller sample of respondents that completed the survey reflected a similar distribution
when compared to the corresponding larger sample sizes.

Q12: What specific resources or types of data were you able to access?
55
FHIR CDA ADT Proprietary APIs Other Files & Formats
Epic
Total respondents: 34
14 10 18 9 16
Cerner
10 7 14 8 12
Allscripts
8 9 11 17 11
eClinicalWorks
3 4 7 2 10
Meditech
0 1 8 2 10
GE Centricity
2 6 8 4 11
McKesson
2 2 5 0 8
Athenahealth
4 6 7 20 7
NextGen
1 1 6 1 12

Health 2.0 EMR API report 2018

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