An App Store for Your EHR? Why Not?

Apr 2, 2009, 4:25 AM, Posted by Steve Downs

Up on the Project HealthDesign blog, Lygeia Ricciardi calls attention to Ken Mandl and Zak Kohane’s perspective article in the New England Journal on the need for a flexible information infrastructure in health care.  In the article, Mandl and Kohane offer a simple prescription – that the infrastructure be designed as a platform upon which many competitive, substitutable applications can be offered.  They cite the Apple iPhone as an example where this has worked successfully:

“The platform separates the system from the functionality provided by the applications. And the applications are substitutable: a consumer can download a calendar reminder system, reject it, and then download another one. The consumer is committed to the platform, but the applications compete on value and cost.”


The idea of separating the infrastructure from the applications has been vital to innovation in the computer industry and was the key to our approach on Project HealthDesign (see my post introducing the program).  We were focused on personal health records, but the notion of applying the idea to the design of the infrastructure that supports the business of health care is getting some attention.  Peter Neupert, who leads Microsoft’s health solutions business, has been calling for this, which should be no surprise since Microsoft knows full well the value of a software platform.  The National Research Council (NRC) released a report in January on Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, in which they also recommend that health care institutions “insist that vendors supply IT that permits the separation of data from applications.” (Disclosure:  Robert Wood Johnson Foundation was a partial funder of the report).

This discussion comes at a critical time for two reasons.  First, the American Recovery and Reinvestment Act includes approximately $19 billion in investments in health IT, so to the extent that the incentives work, we’ll see a tremendous amount of investment in health IT over the next several years.  Second, and perhaps even more importantly, we are on the brink of health reform, which suggests that health care institutions need to be poised for changes in the ways that they work.  Mandl and Kohane make the point that macro trends such as the aging population and work force shortages will put pressure on the system to adapt and therefore the information infrastructure needs to be sufficiently flexible.  The NRC committee, led by Bill Stead and shepherded by Herb Lin, noted that

“IT is often implemented in systems in a monolithic fashion that makes even small changes hard to introduce ...IT applications appear designed largely to automate tasks or business processes”

and recommended that

“… any IT-based infrastructure to support today’s health care needs must be designed to accommodate changes in roles and process tomorrow—a point suggesting that architectures based on standard interconnection protocols are much easier to change in comparison to monolithic, tightly integrated all encompassing systems. Otherwise, even deployment of health care IT successful in solving a problem today could stand in the way of solving tomorrow’s challenges.” 

So we’re at an interesting and challenging confluence:  there is a tremendous need for flexibility in the face of change at the same time that the country is making major investments in the infrastructure. Will these investments result in an infrastructure that is sufficiently flexible to handle the change?  Good question.  I might be wrong on this – and would love to be proven so – but I certainly don’t see a lot of the health IT industry offering the platform-application model that can enable that flexibility.  The approach makes such intuitive sense and when you look at the successes of other platforms like the iPhone, Google Maps, eBay and Amazon, one gets the feeling that we’ll all look back and chuckle about the days when electronic health records did not support 3rd party applications.  But maybe not – there might be really good counter-arguments that support a model where the applications are tightly integrated with the infrastructure – I’d love to hear them and get some discussion going.  In the meantime, I’ll go back to one of the crucial arguments for opening up a platform to 3rd-party development – it unleashes armies of creative developers who come up with ingenious ideas that one company could never imagine.  Check out this ad for Apple’s app store.  The level – it’s brilliant.