Electronic Health Record (EHR) integration is one of the most critical—and complex—components of healthcare software development. Whether you're building a patient portal, telemedicine platform, or specialized clinical application, seamless integration with your EHR system is essential for delivering value to users and ensuring data accuracy.
Choosing the right EHR integration partner can mean the difference between a smooth implementation and months of technical headaches. At Of Ash and Fire, we've successfully integrated healthcare applications with Epic, Cerner, Allscripts, athenahealth, and numerous other EHR platforms. Through this experience, we've learned what separates exceptional integration partners from those who overpromise and underdeliver.
This guide will help you evaluate potential partners and ask the right questions to ensure a successful EHR integration project.
Understanding EHR Integration Complexity
Before diving into partner selection, it's important to understand why EHR integration is uniquely challenging:
Multiple Integration Standards
HL7 v2.x: The legacy standard still widely used for ADT (Admission, Discharge, Transfer) messages, lab results, and other clinical data. HL7 v2 messages are text-based and require custom parsing.
HL7 FHIR (Fast Healthcare Interoperability Resources): The modern standard using RESTful APIs and JSON/XML formats. FHIR is increasingly preferred for new integrations due to its flexibility and ease of use.
HL7 CDA (Clinical Document Architecture): Used for sharing clinical documents like discharge summaries and continuity of care documents.
Proprietary APIs: Many EHR vendors offer their own APIs alongside standard protocols. Epic's MyChart API, Cerner's MillenniumObjects, and athenaNet APIs each have unique characteristics.
Vendor-Specific Challenges
Each major EHR platform has its own:
- Certification requirements
- Sandbox environments and testing procedures
- Documentation quality and accessibility
- Integration costs and licensing models
- Technical support responsiveness
- Implementation timelines
Data Mapping Complexity
EHR systems organize clinical data differently. Mapping your application's data model to the EHR's structure—and vice versa—requires deep healthcare domain knowledge and technical expertise.
Key Questions to Ask Potential Integration Partners
1. EHR-Specific Experience
Questions to ask:
- Have you integrated with our specific EHR system (Epic, Cerner, etc.) before?
- Which version(s) of the EHR have you worked with?
- Can you provide references from clients using the same EHR?
- What types of data have you integrated (demographics, clinical notes, lab results, medications, allergies, vitals)?
- Have you worked with our EHR's FHIR implementation?
Why it matters: Generic EHR integration experience isn't enough. Each system has unique quirks, undocumented behaviors, and vendor-specific requirements. A partner with specific experience in your EHR will anticipate challenges and accelerate implementation.
Red flags:
- "We can integrate with any EHR" without specific examples
- No previous integration with your EHR vendor
- Unable to discuss technical details of their past integrations
2. Certification and Compliance
Questions to ask:
- Are you certified/registered with our EHR vendor's developer program?
- Do you have experience obtaining EHR vendor certifications?
- What HIPAA compliance measures do you implement for integrations?
- Have you completed security assessments required by major EHR vendors?
- Do you have experience with ONC certification requirements (if applicable)?
Why it matters: Many EHR vendors require formal certification or registration before allowing production integrations. Partners without this experience may discover unexpected requirements late in the project.
What to look for:
- Active registration with relevant EHR vendor developer programs
- Portfolio of certified applications
- Understanding of HITRUST, SOC 2, and other healthcare security frameworks
3. Technical Approach and Architecture
Questions to ask:
- What integration standards do you recommend for our use case (HL7 v2, FHIR, CDA, proprietary API)?
- How do you handle real-time vs. batch integration scenarios?
- What's your approach to error handling and data reconciliation?
- How do you manage API rate limits and performance optimization?
- What monitoring and alerting do you implement for integrations?
- How do you handle EHR system downtime or maintenance windows?
Why it matters: The technical architecture determines reliability, performance, and maintainability. A well-designed integration anticipates failure scenarios and implements robust error handling.
Technical depth to expect: Partners should discuss specific technologies (integration engines like Mirth Connect, cloud integration platforms, message queuing systems) and architectural patterns (synchronous vs. asynchronous, event-driven design, etc.).
4. Data Mapping and Transformation
Questions to ask:
- How do you approach data mapping between our application and the EHR?
- What's your process for handling data that doesn't map cleanly?
- How do you manage code sets and terminology standards (LOINC, SNOMED, ICD-10)?
- Can you handle bidirectional data synchronization?
- What's your approach to maintaining data integrity?
Why it matters: Data mapping is often the most time-consuming aspect of EHR integration. Partners need healthcare domain expertise to map clinical concepts correctly.
Look for: Discussion of clinical workflows, understanding of medical terminology, experience with terminology mapping tools and services.
5. Timeline and Project Management
Questions to ask:
- What's a realistic timeline for our integration project?
- What factors could extend the timeline?
- What's required from our internal team and EHR vendor?
- What's your process for managing scope and expectations?
- How do you handle vendor delays (EHR sandbox access, certification reviews)?
Why it matters: EHR integrations involve multiple stakeholders (your team, the integration partner, the EHR vendor, and often your EHR implementation partner). Realistic timelines and strong project management are essential.
Realistic timelines:
- Simple FHIR read-only integration: 6-12 weeks
- Bidirectional FHIR integration: 12-20 weeks
- Complex HL7 v2 integration: 16-24 weeks
- Epic App Orchard certification: Add 8-12 weeks
- Cerner Code validation: Add 6-10 weeks
6. Testing and Validation
Questions to ask:
- What's your testing approach for EHR integrations?
- Do you have access to sandbox environments for our EHR?
- How do you test edge cases and error conditions?
- What's your process for user acceptance testing?
- How do you validate clinical accuracy of data exchanges?
Why it matters: Thorough testing is critical when patient data is involved. Insufficient testing can lead to data corruption, patient safety issues, or compliance violations.
Comprehensive testing includes:
- Unit testing of integration components
- Integration testing in sandbox environments
- End-to-end workflow testing
- Performance and load testing
- Security testing
- Clinical validation with healthcare professionals
7. Ongoing Support and Maintenance
Questions to ask:
- What ongoing support do you provide post-implementation?
- How do you handle EHR upgrades and version changes?
- What's your process for troubleshooting integration issues?
- Do you provide monitoring and alerting services?
- What are the costs for ongoing maintenance and support?
Why it matters: EHR integration isn't "set it and forget it." EHR vendors release updates, APIs evolve, and issues arise. Ongoing support is essential.
Support should include:
- 24/7 monitoring of integration health
- Proactive notification of issues
- Defined SLAs for issue resolution
- Regular reviews and optimization
- Support for EHR version upgrades
Evaluating Major EHR Platforms
Epic Systems
Market position: Largest EHR vendor in the U.S., dominant in large hospital systems
Integration considerations:
- Interconnect certification required for many integration types
- App Orchard marketplace for publishing patient-facing apps
- MyChart API for patient portal integrations
- FHIR implementation is robust and well-documented
- Sandbox access available through Epic's developer program
- Timeline: Generally 4-6 months for certification
- Costs: Annual certification fees and App Orchard listing fees may apply
Partner must-haves:
- Previous Epic integration experience
- Active Epic developer program membership
- Understanding of Epic's certification process
- Familiarity with Epic-specific terminology (Chronicles database, MyChart, Hyperspace)
Cerner (Oracle Health)
Market position: Second-largest EHR vendor, strong in community hospitals
Integration considerations:
- Cerner Code validation required for certified integrations
- MillenniumObjects API for programmatic access
- FHIR support improving but historically less mature than Epic's
- CareAware integration for device connectivity
- Sandbox environments available through Cerner Code program
- Timeline: 3-5 months for code validation
- Recent changes: Oracle acquisition may impact programs and processes
Partner must-haves:
- Experience with Cerner's specific data model
- Understanding of MillenniumObjects or FHIR implementation
- Cerner Code program registration
- Knowledge of CCL (Cerner Command Language) if needed
Allscripts, athenahealth, and Others
Integration approaches vary:
- Allscripts: Developer Program with sandbox access, FHIR and proprietary APIs
- athenahealth: athenaNet API with well-documented RESTful interface
- eClinicalWorks: API access through eClinicalMobile program
- NextGen: Mirth Connect integration engine commonly used
General considerations:
- Smaller vendors may have less mature developer programs
- Documentation quality varies significantly
- Sandbox availability may be limited
- Direct vendor relationships may be necessary
Understanding FHIR vs. HL7 v2
When to Use FHIR
Best for:
- Patient portal integrations
- Mobile health applications
- Modern, patient-facing applications
- Read-heavy workflows (displaying EHR data)
- Newer EHR implementations
Advantages:
- RESTful API design (familiar to modern developers)
- JSON format (easy to parse and work with)
- Strong standardization across vendors
- Growing ecosystem of tools and libraries
- Better support for consumer-facing applications
Limitations:
- Not all data types available via FHIR yet
- Some EHR vendors' FHIR implementations lag behind others
- May not support all write operations needed
When to Use HL7 v2
Best for:
- Hospital system integrations
- Lab result interfaces
- ADT (Admission/Discharge/Transfer) feeds
- Legacy system integrations
- High-volume, real-time messaging
Advantages:
- Mature standard with decades of implementation experience
- Supported by virtually all EHR systems
- Rich message types for clinical workflows
- Proven reliability for high-volume scenarios
Limitations:
- Text-based format requires custom parsing
- Less developer-friendly than FHIR
- Vendor implementations vary significantly
- Requires integration engine or middleware (typically)
Integration Costs to Expect
One-Time Costs
- Development: $50,000 - $250,000+ depending on complexity
- EHR vendor certification/validation: $5,000 - $25,000
- Testing and quality assurance: $10,000 - $40,000
- Project management and coordination: $15,000 - $50,000
Ongoing Costs
- Maintenance and support: $1,000 - $5,000/month
- Annual EHR vendor fees: $2,000 - $15,000/year
- Monitoring and infrastructure: $500 - $2,000/month
- Update support: $5,000 - $20,000/year
Note: Costs vary dramatically based on integration scope, data types, number of EHR instances, and specific requirements.
Red Flags to Watch For
During Partner Evaluation
- Vague timelines or overly aggressive estimates - EHR integration requires coordination with multiple parties
- "We'll figure it out as we go" - Lack of clear methodology indicates inexperience
- No clinical domain knowledge - Technical skills alone aren't sufficient
- Unable to discuss specific technical challenges - Generic responses indicate limited real-world experience
- No mention of testing strategy - Thorough testing is critical for patient data
- Dismissive of vendor certification requirements - Attempting shortcuts can derail projects
During Implementation
- Scope creep without formal change management - Integration complexity often reveals new requirements
- Long periods without progress updates - EHR vendor dependencies shouldn't mean radio silence
- Reluctance to involve clinical staff in validation - Technical accuracy doesn't guarantee clinical accuracy
- Testing only "happy path" scenarios - Real-world data is messy; test edge cases thoroughly
Making the Final Decision
When evaluating partners, create a scorecard covering:
- EHR-specific experience (30%)
- Technical capabilities (25%)
- Project management and communication (20%)
- Reference quality and client satisfaction (15%)
- Cost and timeline realism (10%)
Don't make cost the primary decision factor. A cheaper partner without relevant experience will likely cost more through project delays, quality issues, and rework.
Working with Of Ash and Fire
At Of Ash and Fire, we've successfully integrated healthcare applications with Epic, Cerner, Allscripts, athenahealth, and other major EHR platforms. Our team combines deep technical expertise with healthcare domain knowledge, ensuring your integration is:
- Clinically accurate: We understand healthcare workflows and terminology
- Technically sound: Modern architecture with robust error handling
- Compliant: HIPAA-compliant design with comprehensive security measures
- Well-tested: Rigorous testing including clinical validation
- Supported: Ongoing monitoring and maintenance to ensure reliability
Next Steps
Ready to discuss your EHR integration project? Contact us for a consultation. We'll assess your specific requirements, recommend the best integration approach, and provide a detailed proposal with realistic timelines and costs.
Choosing the right EHR integration partner is one of the most important decisions you'll make for your healthcare software project. Take the time to evaluate thoroughly—your users and your organization will benefit from the investment.