A Quick Introduction to Effectively Integrating an App with Cerner

McKinsey predicts the healthcare software technology market will grow through 2027, especially in patient engagement and clinical decision-making solutions. EHR companies will focus on improving the patient and clinician experience. Cerner, with a US market share of over 20%, will be one provider looking to improve its market share through in-house and third-party applications.

However, Oracle’s acquisition of Cerner in June 2022 has complicated the landscape. According to Oracle, the acquisition will incorporate Cerner’s clinical capabilities with Oracles’s automation and analytical expertise to deliver an enterprise-wide healthcare information system for the cloud. The Oracle Cerner product has been rebranded to Oracle Health.

In December 2023, Oracle stated that it was moving many of Cerner’s Millennium customers to Oracle Cloud Infrastructure (OCI) and upgrading Millennium a piece at a time to operate in the cloud. The company is “rewriting” the health and intelligence platform Cerner HealthIntent for OCI deployment. What that means for third-party solutions is to be determined, but a brief review of Cerner Millenium can help inform developers looking at Cerner integration.

What is Cerner Millennium?

Cerner Millennium is the umbrella term for all Cerner healthcare applications, with PowerChart as the base charting application. The available tools depend on the licensed functionality in each system build. 

Access is also controlled through roles, specialties, and workflows. Identifying applications can be challenging as system components have been renamed since its initial release in 1984. Oracle has not indicated what naming conventions will carry over to Oracle Health.

Related: A Quick Guide to EHR Integration for Health Apps

Cerner was founded in 1979 but did not release PathNet until 1984. It was designed to support hospital pathology departments. Other applications followed for operating rooms (SurgiNet), radiology (RadNet), pharmacies (PharmNet), and emergency departments (FirstNet). 

Today, Cerner has over a dozen applications, such as Ambulatory, CareNet, and CPOE (Computerized Physician Order Entry). Active applications appear on the Application Bar of MPages.

Cerner uses the following standards for third-party integration:

• SMART (Substitutable Medical Apps and Reusable Technology)
• SMART on FHIR (International Fast Healthcare Interoperability Resources)
• HL7 (Health Level Seven) FHIR

Information regarding available functionality based on release level can be found on the Oracle Cerner website. Given the possible configurations that an application may encounter, developers should confirm the standards to ensure compatibility.

What are the Integration Options?

Although Cerner lists SMART and SMART on FHIR as separate integration standards, both implementations require FHIR. Cerner may have older versions of HL7 standards without FHIR at customer locations; however, the company only supports the HL7 FHIR standard.

SMART

Cerner’s SMART on FHIR implementation leverages the FHIR framework to retrieve EHR data based on the patient context. The system does not require the ongoing use of FHIR beyond identifying the authorization server. Both SMART and SMART on FHIR require a FHIR server to be present for applications to launch. 

SMART on FHIR integration uses the FHIR framework for accessing EHR information. Cerner’s SMART interface allows applications to access a variety of data sources. Developers can choose from third-party, private, and proprietary data sources. They are not restricted to FHIR-supplied information. Cerner also offers SMART application developers access to proprietary elements such as objects, services, and scripts. 

HL7 FHIR

HL7 is a long-standing message interface that facilitates the exchange of structured data. It was designed as a point-to-point protocol, requiring a hub if the interface needed to communicate with multiple endpoints. Incorporating FHIR into the HL7 interface allows Cerner to leverage the FHIR framework for expanded integration functionality.

How Are Non-Cerner Applications Accessed?

Access to third-party applications depends on the standard and the application. Users can access applications through drop-downs, ribbons, or true workflow interoperability. Each access method requires careful evaluation to ensure compatibility and assess the scope of work.

Drop-Downs

The simplest integration is to have an application appear in a drop-down. Each application has a SMART on FHIR button that the clinician or others can select to access the application. The button to launch the application is only visible from the drop-down.

While drop-down menus within the EHR provide a basic level of integration for third-party applications, this approach falls short of delivering a truly optimized clinical workflow. Too often, clinicians are forced to disrupt their train of thought, hunt through nested menus, and manually launch separate applications.

Ribbons

Third-party applications can use ribbons to alert users to recommendations, relevant information, or insights. Instead of scrolling through a drop-down, information is displayed. If physicians decide to use information in the ribbon, they must manually transfer the information to the EHR. 

While ribbons provide a more visible way to surface third-party application data compared to drop-down menus, this approach still requires clinicians to manually transfer any relevant information into the EHR. This fragmented workflow introduces opportunities for error, fatigue, and compromised data integrity.

Workflows

True workflow interoperability is bi-directional, taking a different approach by deeply embedding third-party insights, recommendations, and documentation capabilities as seamless interface elements directly within the clinician’s active EHR session. This combines the display capabilities of ribbons with the write capabilities of FHIR. Third-party applications can be launched in context with zero clicks when the care team logs into the EHR or views a patient chat. Decisions made by care teams in third party applications are written to EHR.

Related: How EMR/EHR Workflow Integrations Are Improving Healthcare

Integrating third-party applications into Cerner workflows allows applications to generate notifications, ribbons, sidebars, and badges in context—to display patient-specific recommendations. The decisions made based on these recommendations can be written to the appropriate EHR section automatically, without the need to copy and paste content.

What Access Method to Use

Deciding on the integration method for an application depends on more than just the technology. It depends on the business goals and the return on investment. These factors, along with the development triangle of time, resources, and functionality, influence the final design. To understand how users view the different access methods, developers need to visualize MPages.

MPages

Cerner’s MPages are present in the Organizer or Chart levels of PowerChart. Millennium also allows users to designate which view appears on their Home page. The amount of information accessible through an MPage can be overwhelming, with many reviewers indicating a steep learning curve depending on the workflows.

Drop-downs

Drop-downs provide a listing of third-party applications available to clinicians and non-clinicians. Cerner users must go to the drop-down before scrolling through the list of available applications to find the application that can help them treat a specific patient. Unless users know about an application, they are unlikely to search the list in the drop-down menu for an applicable tool.

Patient engagement is time-sensitive. Physicians can’t waste valuable minutes trying to locate a tool from an unlimited list of applications. Initially, they may try different options, but the benefit must offset the lost time for users to continue using the application. Developers are well aware of the frustrations that come with toggling from application to application. 

Ribbons

With ribbons, recommendations can be displayed but do not write decisions and data to EHRs. The data displays automatically. However, clinicians must manually transfer the information to EHRs. A 2022 report found that physicians spend between three and six hours per day on charting, with an average of 4.5. Physicians, regardless of specialty, continue to spend more “pajama time” keeping up with administrative tasks.

Requiring transfer of information, whether through copy and paste or data entry, adds to the hours spent charting. The manual process introduces errors if the copy and paste may not include all pertinent information or the data is entered incorrectly in the rush to update EHRs. 

Workflows

A recent study in Harvard Business Review found that across all industries, people spend 9% of their time toggling between applications. That’s five weeks. For a primary care physician in private practice, that’s 300 patients that were not seen. (Assuming 25 days at an average of 12 patients per day.) The same study reported that the “context switching” added to fatigue and employee burnout. 

Effectively integrating applications into Cerner’s workflows minimizes the need for users to toggle between applications. Instead, recommendations based on patient context can be displayed through pop-ups, ribbons, sidebars, and badges. When decisions are made based on these recommendations, the decision can be automatically written to the EHR. True workflow integration improves EHR accuracy, maximizes patient interactions, and reduces burnout.

Adding this level of integration does not have to be difficult. Insiteflow offers a decision workflow interoperability SaaS platform that integrates third-party applications with Cerner EHRs. With Insiteflow, an application becomes a valuable resource that improves patient care and relieves clinician stress. Contact us to learn how your application can become a valued part of Oracle Cerner’s EHR solution, increasing value for clinicians and helping improve patient care.