New ONC research shows a more than 20% rise in the number of apps that integrate with certified electronic health records (EHRs).

A manuscript highlighting the findings of this research was recently published in the Journal of the American Medical Informatics Association: “The Ecosystem of Apps and Software integrated with Certified Health Information Technology”. Our study analyzed apps that were discoverable in app galleries managed by EHR developers – Allscripts, athenahealth, Cerner Corporation and Epic Systems Corporation – as well as the SMART App Gallery. Specifically, ONC wanted to understand the growth of the app market, the variety of available app functions, how these apps connect to EHRs, and if the apps support the Health Level Seven® (HL7) Fast Healthcare Interoperability Resources® (FHIR) standard.

This research provides baseline measurement and insights into this market prior to finalization of the ONC Cures Act Final Rule and its implementation. This research continues, today, as one way to measure the impact of ONC rulemaking and understand changes in the market.

What the Data Says

Our research showed that the total number of unique apps and developers increased from 600 to 734 and 517 to 610, respectively, during 2020.

Administrative apps that handled scheduling, check-in, and billing made up 42% of available apps. Clinical apps were also common, comprising 38% of apps; these apps perform automated tasks, population health, telehealth, and clinical decision support. Other apps focused on care management (31%), patient engagement (20%), and research (5%).

Growth of FHIR-enabled apps remained stagnant. While more apps support FHIR (161 in 2020 compared to 112 in 2019), there was not a statistically significant increase in the proportion of FHIR-enabled apps among all apps (19% in 2019 compared to 22% in 2020).

Some potential explanations for this modest growth include:

• Administrative apps, the most common type of app, typically do not support FHIR; at least not at the same rate as apps for clinical use or care management.
• FHIR apps typically get developed around a set of specific use cases. FHIR resources are limited to the exchange of particular data elements, which may reduce their overall prevalence. As the number of use cases grow, so should the number of applications.

The role of secure, standards-based application programming interfaces (APIs) will be one area for researchers to explore further. Standards-based APIs may help apps connect to multiple EHR data systems without the added effort of using proprietary APIs for each integration. FHIR is widely supported by health IT developers, many of which are market leaders. Tracking the support of FHIR among apps over time will inform how apps and the EHR data systems to which they connect are using standards-based APIs to enable these integrations. If standardization makes integrations easier, more end-users can connect to their data.

Looking for Continued Growth

At ONC, we work with other government, industry, and academic partners to improve access and use of electronic health information. This includes looking at ways to support competition and the use of best-of-breed functions.

In this study, the data showed that there is still room for growth and variation in the apps available. Updates to the ONC Health IT Certification Program resulting from the ONC Cures Act Final Rule are intended to support a more robust ecosystem of third-party apps. By the end of 2022 many certified health IT developers will be required to support FHIR-based, standardized APIs for patient and population level services and they will need to abide by new API “Conditions and Maintenance of Certification” requirements to promote transparent and competitive business practices. Together these updates should help improve the use of APIs by third-party app developers. The published research examined the entire ecosystem of apps – both provider and consumer-facing – that integrated with EHRs. This ongoing study shall further examine consumer-facing apps, particularly those that enable patient medical record access, in future research.

Again, the goal of this study is to set a baseline. ONC will continue to monitor this growth in the coming years to see what impacts the rule will have on app development and integration with certified health IT, and if additional policies or practices could accelerate the exchange and access of electronic health information through third-party apps.