If you're building a HealthTech product and trying to break into the provider market, one question will surface early and often: "How do we integrate with an EMR?"

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At Invene, we've integrated with EMRs dozens, probably hundreds, of times, across inpatient systems like Epic and Cerner to niche players like athena, eClinicalWorks, and TouchWorks. Over time, we've refined a strategic and technical framework to help both startups and enterprise innovators navigate the complexity. It covers four foundational pillars: Why, What, Who, and Which.

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WHY: What's Driving This Integration?

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Every integration should begin with strategy, not technology.

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Here's why integration matters:

• Embed into provider workflows – Solutions embedded into EMRs reduce context switching and increase adoption. A solution that eliminates context-switching (e.g., updating patient info in two places) offers tangible workflow improvements for care teams, making it far more likely that hospitals or clinics will adopt and continue using it.
• Access critical data – Real-time access to labs, meds, schedules, and other clinical data improves outcomes. This data-driven boost can improve your product's insights and demonstrate greater value to customers. In many cases, integrating is essential to deliver the promised clinical insights or automation.
• Win deals – Lack of integration is a non-starter for many providers. For many healthcare organizations, lack of EMR integration is a deal-breaker. Early integration can become a competitive advantage to acquire new clients or retain existing ones. By offering seamless data exchange with the EMR, you can remove a common barrier to closing deals.
• Unlock new revenue streams – Marketplaces like Epic App Orchard and Cerner code offer visibility and procurement pathways. However, these come with costs—often around $5,000 per app registration plus a percentage of revenue for paid apps. These "integration taxes" must be factored into your business model to prevent erosion of profitability.

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Too many startups treat integration as a technical milestone. Instead, treat it as a revenue enabler. Who pays you, and how does integration accelerate that? Don't treat integration as just a technical checkbox, treat it as a revenue driver by focusing on how it enhances your solution's value in practice.

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WHAT: What Kind of Integration Are You Doing?

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The most important distinction is pull vs. push:

• Pull integrations retrieve data from the EMR (read-only). These integrations are generally easier and lower-risk, often using standardized APIs (particularly FHIR in modern systems). Your product can query patient info, appointments, or clinical data from the EHR without altering anything on the EHR side. Ideal for v1 products.
• Push integrations write data into the EMR. This triggers IT governance and can extend sales cycles by 3–6 months. Hospitals typically require extra IT scrutiny for any solution that writes into their official record. Allowing a third-party app to insert data triggers strict review processes, mapping to the EMR's data model, and validation to ensure patient safety.

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For early-stage HealthTech companies: start with pull. You'll reduce sales friction, shorten implementation timelines, and get into production faster.

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Integration complexity an implementation

Even "simple" integrations require navigating technical and workflow complexity. Each EMR has its own integration surfaces – some provide RESTful APIs, others rely on HL7 v2 message feeds or proprietary SDKs. Often multiple methods are used in combination.

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It's important to note that no two hospital interfaces are exactly alike – even with the same vendor software, site-specific customizations (custom fields, code sets, workflows) mean an integration that works at Hospital A might break at Hospital B without adjustments. This variability demands careful mapping and testing for each deployment. Startups must plan for this in their timelines, as integration often takes weeks per site for testing and tweaking.

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WHO: Which EMR Are You Integrating With First?

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Your resources are limited. Prioritize.

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Start with these questions:

1. Which EMR does your beta customer use? If you don't have a beta site, get one.
2. Which EMR dominates your target market? Each segment has a dominant player:

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You don't need 10 EMR integrations. You need the one that moves your deal pipeline.

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Integration Partners and Ecosystems

Another aspect to consider is whether to handle integration directly or use partners. If you choose Epic, for instance, you'll likely need to join their App Orchard program to get full API access and to deploy at customer sites. This provides a formal pathway to integration and even co-marketing via the vendor's marketplace, but be mindful of the costs.

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Alternatively, you might work with interoperability service providers (like Redox, Zeus, MuleSoft) that have pre-built connections to multiple EMRs. These can act as a middleware layer, so you build to one API and let the service translate to each EMR's interface. This approach can accelerate multi-EMR support, although it comes with subscription costs and reliance on a third party.

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Many startups use a hybrid strategy: integrate directly with one major EMR initially (to prove value and avoid middleware cost), but plan to use an integration-platform-as-a-service to scale to others later.

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WHICH: What Method Will You Use to Integrate?

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There are five technical methods for EMR integration. Each has tradeoffs:

Emerging Standards: SMART on FHIR

One encouraging development is the growing adoption of standards like FHIR and the emergence of SMART on FHIR apps. These allow a third-party app to run inside the EHR (like a plugin) and use standardized APIs, which can significantly reduce custom integration effort. Major EHRs now support SMART on FHIR, and some startups have achieved dramatically shorter integration timelines using this route.

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Final Thoughts

There's no one-size-fits-all answer to EMR integration. But there is a playbook:

• Start with strategy. Know why you're integrating.
• Start simple. Pull data before you push it.
• Start focused. Integrate the EMR your first customer uses.
• Start safe. Choose secure, sustainable integration methods.

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There is no silver bullet for EMR integration. Each approach has trade-offs, and what works best will depend on the startup's use case and the partner clinic/hospital's IT environment. Often, the pragmatic choice is to start with the least invasive method that meets your needs, and evolve if necessary.

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Always keep the end-user workflow in mind: the ultimate goal is to deliver the right information to the right place at the right time, securely and efficiently. Whether that's achieved via a nightly batch file or a cutting-edge FHIR API is a tactical detail – one that should be guided by both technical feasibility and strategic alignment with your customers.

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Invene has helped dozens of startups and enterprises navigate this. If you're considering integration, we're happy to talk.