Primary Care: The Mother of all APIs

TL;DR Imagine healthcare services as API calls. The majority of them go through primary care because it is one of the main entry points of care and because of our extensive scope of services. EMR-based API calls (e.g. prescriptions, labs, etc.) have clearly defined inputs and outputs. These are ripe for automation with protocols and technology. But the magic of primary care lies in ill-defined API calls (e.g. care coordination, continuity of care, community care resources, etc.) that have messy inputs and outputs. To make an impact in primary care through technology, we need to rethink what we consider to be the real challenges.

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Primary care physicians (PCPs) have historically been described as quarterbacks or gatekeepers of care, but to our knowledge no one has conceptualized them as universal application programming interfaces (APIs) of healthcare. In this article, we illustrate

• why interoperability is their superpower that no other specialty can match 

• how solving primary care challenges impacts the entire healthcare ecosystem

• what types of collaborations are needed to build solutions that resonate with patients, clinicians, and payers alike

By bringing together clinical and technical domains, we aim to catalyze a new generation of primary care builders that traverse across healthcare silos. We demystify how clinical information flows in care delivery and identify missed opportunities for disruption. 

Let’s review the fundamentals. What exactly are APIs? 

An API is an interface between different software applications, allowing them to communicate with each other in an agreed upon format and exchange information. APIs come with codebooks (idealistically), maintained and updated to define the available calls and the parameters of the expected return. API calls are specific messages sent through this communicator. Common API calls include GET (gathering data), POST (adding new data), and PUT (updating existing data). 

What types of “API calls” do doctors make?

Physicians are the interface between patients and the healthcare ecosystem. On the surface, they GET(symptoms), POST(prescriptions), and PUT(treatment plans). But in practice, their role extends past simply translating from patient to health system and dives deep into the complex bureaucratic abyss that is navigating and operating health systems. Figure 1 illustrates the diverse array of API-like calls primary care doctors make, showcasing the multifaceted nature of their responsibilities in care delivery.

Figure 1: “API calls” in primary care

The superpower of interoperability across specialties

Most people do not understand what primary care is capable of. PCPs now manage a growing range of conditions that previously warranted specialist interventions. This is driven by a modern healthcare paradox: patients are much sicker yet live longer. To keep pace, PCPs leverage technological advancements in data consolidation, distribution, and search (e.g. UpToDate, DynaMed, AAFP). Such clinical decision support tools have effectively diluted information asymmetry in healthcare. What used to be in the hands of specialists is now at the fingertips of primary care doctors (and will eventually enter the knowledge domain of patients themselves allowing them to “practice at the top of their license”). Thus, symptoms or diagnoses that used to trigger immediate Referral APIs now route to the PCP Knowledge APIs. This increases the significance of PCP contributions in healthcare because primary care goes further into every field by managing increasing complex medical conditions across multiple organ systems. See Figure 2 to delve deeper into the Knowledge API calls to better understand the breadth of primary care.

Figure 2: Commonly treated conditions in primary care across multiple verticals.

Here are a few examples of formerly specialist care that is now commonly managed by PCPs:

• Cardiology: Cardiologists often defer the management of anticoagulation (e.g. warfarin therapy) or treating hypertension to PCPs unless the patient fails to respond to multiple treatments.

• Nephrology: Nephrologists prefer not to engage in managing acute kidney injuries (AKIs) that can be addressed in primary care or see patients with chronic kidney disease until it progresses to stage 4.

• Endocrinology: The management of conditions like hypothyroidism or type 2 diabetes is increasingly being left to PCPs unless the patient shows non-responsiveness to a range of treatments at the primary care level.

Several market and practice trends are also driving this change:

• Logistical challenges: Accessing most specialist care takes longer than getting an appointment with a PCP who tackle the burden of patient needs by extending their scope of practice. This phenomenon is particularly true in rural communities.

• Increased specialization: Specialists are increasingly focusing on highly complex cases and PCPs are managing the growing pool of moderate complexity conditions.

• Value-based care models: These models emphasize reducing unnecessary escalations in care to manage healthcare costs effectively. Consequently, the responsibility falls on PCPs to minimize referrals and manage more conditions in-house, thereby reducing the financial risk for patient populations.

The challenges of interoperability

As the scope of primary care has expanded to manage more complex patient needs and care offerings, so too has the influx of data into the practice. This entails handling incoming API feeds with lab and imaging results, reports from specialist referrals, request for DME orders and prescription refills, and also the inbound from patients and their families through phone calls, emails, and direct portal messages. The volume of these inbound signals can overwhelm PCPs, the equivalent of generating an HTTP error 429 due to “too many requests.” In medicine, we call that burnout.

Volume of API calls isn’t the only issue faced by PCPs. Many of the healthcare API calls are “sloppy,” with no maintained codebooks. PCPs are essentially functioning like analog switchboard operators trying to appropriately navigate this disorganized system. The reality is that AI cannot effectively replace this role if all entry and exit points within the healthcare network remain chaotic, ill-defined, and often not even digital. The connection points within this system are haphazard and heavily reliant on local or insider knowledge. For example, there's no universal codebook that guides interactions with specialists or diagnostic services across networks. When primary care does decide to refer to a specialist, the PCP is responsible to plug into the specialist system through the Care Coordination and Referral API calls, capturing both patients’ entry and exit points across disparate institutions. Much of this interoperability is achieved through labor-intensive manual processes (e.g. making phone calls, sifting through faxes, etc.) - a system with significant latency. This lack of standardized and accessible information creates a significant barrier to delivering high-quality care.

The primary care switchboard circa 2024 😭

The problem of ill-defined API calls

Physicians often have a bad reputation for being too focused on the EMR when interacting with patients. This EMR-centric focus stems from the volume of EMR-based API calls they are expected to handle during an office visit (e.g. documentation and billing requirements, ordering of labs and tests, etc.). These API calls in the EMR are often the better defined ones. As a result, AI solutions are targeting the “easier” or less messy API operations, such as refilling meds (e.g. Prescryptive), interpreting labs (e.g. Elaborate), automating billing (e.g. Diagnoss), or synthesizing medical knowledge from journals (e.g. Open Evidence). These solutions tackle the issue of volume overload, but the opportunities to make a real difference lie elsewhere. 

API calls outside of EMR are less clearly defined. Admin API calls are worth a special mention because of the range of skills needed to handle this category of tasks within local contexts (e.g. paperwork for FMLA, DME, disability placards, or workers compensation). These still exist primarily as printed paper forms which are not standardized, and often are full of bureaucracy at best, and intentional obfuscation at worst. The completion of these admin tasks is invisible to medicine when completed as expected but becomes painfully prominent when the tasks (or “packets”) get dropped. For example, incomplete FMLA forms can mean no household income for a patient during a medical leave. Incomplete records retrieval for pre-op evaluations can derail elective surgeries and cause scheduling nightmares, create frustration for patients, and lead to avoidable lost revenue for the surgeons. It is no surprise that entire startups exist to fill the gap of guiding patients through the healthcare labyrinth for pre-ops (e.g. Orchestra Health) or during health scares (e.g. Carte Clinics). But these problems and approaches tend to rely on localized or regional system knowledge, are human driven, and are time and labor intensive. These tasks are not celebrated in a system that rewards interventions over incremental care.

We also continue to be painfully far away from mapping out API endpoints for interventions addressing social determinants of health, such as resources for food insecurity, domestic violence assistance, housing or transportation needs, and counseling services. While it’s not exactly a physician’s job to deal with the root causes of these predicaments, overlooking them undeniably contributes to worse health outcomes (e.g. we can’t prescribe insulin to a patient who doesn’t have access to refrigeration for storing the medicine). Additionally, outcomes like managed diabetes are often the very metrics that dictate physician pay (e.g. HEDIS measures or ACO performance targets). Thus, the primary care office becomes the de facto home for handling the social needs of patients, even if it is not empowered or resourced to do so. It’s hard to do this at scale because many of the solutions are local with the answers stored in physical 3-ring binders and pamphlets at social service departments rather than in digitally accessible formats like JSON databases.

It is no wonder these are not the target of technology or AI innovation as these problems are not sexy, don’t pay well, are poorly defined, and are hyper-localized and difficult to scale. Only visionary builders motivated by true impact will take on such challenges. Solving for primary care pain points will impact the entire healthcare ecosystem because PCPs are part of the majority of workflows, both upstream or downstream of specialty care. We believe that the most meaningful impact will come from operationalizing and scaling interoperability for the ill-defined API calls.

The path forward 

In light of these challenges, there are two pathways forward. Either we take significant strides to clean up and standardize these connection points, making them more like the meticulously documented APIs of tech companies, or we reinvent how information flows and break out of the legacy system. The first approach requires a concerted effort from all stakeholders – from frontline clinicians, payers, patients and local communities. This transformation demands a fundamental shift in how we view the multitude of touchpoints in healthcare. It calls for a clinical workforce that is much more tech savvy and leadership that is more tech literate. Aligning incentives at scale is going to be difficult. 

The second approach entails a more radical overhaul of healthcare interactions. This requires at least two changes: 1) stronger coupling of PCPs to patients and 2) placing patients, rather than physicians shackled to EMRs, at the center of API calls. Patients are poor navigators of healthcare on their own, but when paired with a trusted expert, chances of finding timely high-quality and low-cost care increase dramatically. Direct primary care is the poster child for this phenomenon. Further synergies will come from decentralizing healthcare API calls to yield leverage to patients similar to how Photon Health has reimagined medication prescribing around the patient experience. As a result, we imagine, just as hospital metrics birthed the field of health system informatics, a new crop of informaticist-PCPs will emerge to help broker API calls for patients – not dissimilar to how doctors help patients interpret lab results today. These roles will serve as the linchpin to managing human and digital care navigation resources, data streams, and systems of record. If digital therapeutics (DTx) make a comeback, informaticist-PCPs are poised to specialize as the platform operators.

This PCP-patient dyad model to co-manage an API hub essentially inverts the current structure where patients have limited visibility or control in healthcare. New companies can tap into these flows to provide supporting services while incumbent players are pressured to reorient business models around consumer preferences. The key is architecting an infrastructure where patients sit at the heart of operations rather than the periphery with proper admin support from their PCP offices. Favorable regulatory changes are equally necessary and maybe then personal health records (PHRs) will make a comeback with the right use case (i.e. rooting for Mere Medical). 

We reimagine primary care as the universal API because PCPs are the connectors of healthcare in its current form. It is exciting to see the progress of the quickly evolving AI technologies automating primary care tasks inside the EMR, but the most impactful work that’s yet to be done lies in the space of ill-defined API calls. We believe that the future of primary care innovation will be shaped by the technologies that extend beyond the clinic walls and strengthen the collaboration between patients and their PCPs. Solving for this will be the next frontier of innovation in healthcare.

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Thank you for reading our musings on opportunities to improve primary care. We are excited to support builders in this space. Don’t hesitate to get in touch!