EHR: Build vs. Buy? The Hybrid Approach – Find Your Sweet Spot with 3 Proven Strategies (Part 3)

In Part 1 and Part 2 of our EHR Implementation Strategy series, we explored the typical requirements for venture-backed startups building in this space, along with key questions to guide your investigation. This installment shares three execution paths to the optimal strategy for most healthtech startups: the hybrid approach.

Most Healthtech Startups Need a Hybrid EHR Strategy

The EHR decision isn’t binary. Successful healthtech companies are taking a hybrid approach—leveraging the compliance and speed-to-market advantages of off-the-shelf solutions while integrating custom components for greater differentiation and flexibility. 

Over the past five years, our team at APrime Technology has helped more than a dozen healthtech startups build, rebuild or improve their EHR platforms. Based on that experience, we’ve come up with three hybrid strategies that cover all budgets, timelines and engineering team skills and sizes: 

1. Buy an EHR and extend it
2. Use modular or headless EHR platforms and build your own UI
3. Leverage middleware and integration platforms

Read on for an in-depth exploration of each option–complete with high-level steps, technical implementation, and a hypothetical case study–along with a decision matrix and responses to common implementation challenges.

Hybrid Approach #1: Buy an EHR and Extend It

Implement a commercial EHR (such as Healthie, Elation or welkin) as your foundation and then build custom extensions, integrations, and user experiences on top of it.

High-Level Steps

1. Select a commercial EHR with robust API capabilities and the necessary clinical workflows for your care model. Note: For many vendors, API access is only included with an enterprise or other higher-priced tier. Be sure to consider this cost in your evaluations.
2. Implement the core EHR system for patient records, scheduling, and clinical documentation.
3. Build custom applications that integrate with and extend the EHR’s functionality.
4. Create differentiated user experiences for patients and providers that connect to the underlying EHR.

Technical Implementation

This approach relies on the EHR vendor’s API ecosystem. Your custom development will typically include:

• Custom web or mobile applications that retrieve and submit data to the EHR.
• Data Mapping layers that transform data between your applications and the EHR.
• Backend services that orchestrate workflows across systems.
• Specialized algorithms or AI tools that enhance the standard EHR functionality.

Your custom components will connect to the EHR via API calls, database connections, or other integration methods, depending on the vendor’s architecture.

Example: The Subscription-Based, Virtual-First Primary Care Startup

MediPrime¹ launched a subscription-based primary care model focusing on preventive health and continuous patient engagement. Instead of building an entire EHR from scratch, they:

1. Implemented Elation, a commercial EHR, for core clinical documentation and medical records.
2. Built a custom mobile app for patients that pulls data from the EHR through API requests.
3. Developed an engagement layer with health tracking, personalized recommendations, and chat functionality.
4. Created provider-facing tools for population health management that analyze EHR data.
5. Added a custom billing system that integrates with the EHR for their membership model.

This hybrid strategy enabled MediPrime to launch in just 3 months—compared to the 9+ months a fully custom solution would have required. Their engineering team could concentrate on developing the distinctive patient experience and preventive health tools that set their service apart, while leveraging proven EHR technology to address clinical documentation requirements and ensure regulatory compliance.

When This Approach Makes Sense

This implementation approach for a hybrid model works best when:

• You want to minimize compliance and security risks.
• Your clinical workflows align with traditional care models that are supported “out of the box”.
• You need to move quickly to market with a compliant solution.
• Your technical team is stronger in frontend/UX than healthcare infrastructure.

Hybrid Approach #2: Use Modular or Headless EHR Platforms

This strategy leverages newer EHR platforms that are specifically designed for customization and extension. Rather than working around a central or monolithic EHR system (like in Approach #1), here you select  specific components purposefully built for integration and generally build your own UI

High-Level Steps

1. Select a modular EHR platform with componentized architecture. (Here’s a great resource with more information on Headless EHRs and sample vendors.)
2. Pick and choose the modules that align with your needs (e.g., scheduling, documentation, billing).
3. Build custom user interfaces that connect to the underlying EHR services.
4. Add specialized modules unique to your care model.

Technical Implementation

• This approach typically involves:
  Custom frontend applications that consume EHR services.
• Microservices architecture where your custom services work alongside EHR modules.
• Event-driven communication between systems to maintain data consistency.

The technical complexity is higher than the first approach but offers more flexibility. Your development team will be constructing an ecosystem rather than simply extending an existing platform. You will often not have any UIs or dashboards provided by the headless EHR vendor.

Example: The Specialized Mental Health Platform

MindCare developed a specialized platform for collaborative mental healthcare, connecting therapists, psychiatrists, and primary care providers.

Extending an existing EHR wouldn’t work because MindCare’s core offering relies on mental health workflows that are fundamentally different from the standard care models provided by conventional EHR structures. In other words, mental health platforms are unique – you need specialized assessment tools, narrative documentation that captures the patient stories, long-term tracking, and truly collaborative care workflows that traditional EHRs simply aren’t designed to handle.

Instead, they:

1. Adopted a headless EHR platform (e.g., Canvas) that provided the clinical data model and FHIR-compliant APIs.
2. Built a completely custom therapist interface optimized for mental health workflows.
3. Developed specialized assessment tools and scoring algorithms.
4. Created a patient app with mood tracking, journaling, and guided exercises.
5. Implemented a care coordination layer that pulls data from the EHR but adds team-based workflows.

The result? MindCare stayed compliant while delivering an experience actually tailored to mental health. Plus, their modular approach meant they could improve individual pieces without tearing apart the whole system when needs evolved.

When This Approach Makes Sense

The modular approach works best when:

• Your workflows diverge significantly from traditional care models.
• User experience is critical to your value proposition.
• You have strong technical resources to manage a more complex back-end architecture along with talented front-end engineers to build the UIs
• You need flexibility to evolve different components at different paces.
• Your business model requires non-standard clinical or operational workflows.

Hybrid Approach #3: Leverage Middleware and Integration Platforms

This strategy focuses on interoperability², allowing your custom applications to work with multiple existing EHRs rather than building or extending a single system. 

High-Level Steps

1. Implement an integration platform³ like Redox, Health Gorilla, or particle.
2. Build connections to existing EHRs in your ecosystem (hospitals, clinics, etc.).
3. Create your core applications focusing on your unique value proposition.
4. Use standardized data models (typically FHIR-based) for consistency across sources.

Technical Implementation

• The technical architecture typically includes:
  Integration engine that normalizes data across systems.
• Data transformation services to convert data between formats.
• API gateway to provide unified access to multiple data sources.
• Caching and synchronization mechanisms to handle disconnected operations.
• Business logic layer implementing your unique workflows.

This approach emphasizes interoperability over ownership of the entire stack.

Example: The Care Coordination Platform

CoordinateCare faced a common healthcare challenge: patients receiving treatment across multiple providers and health systems, with fragmented information scattered across different EHRs. Rather than attempting to replace these entrenched systems, they took a more practical approach and:

1. Implemented Redox as their integration platform.
2. Connected that integration platform to several major EHR systems (including Epic or Athena) at partner hospitals.
3. Built a custom care navigation application that aggregates patient data from these various sources.
4. Developed workflow tools for care coordinators to track patients across systems.
5. Created a patient-facing mobile app showing a unified view of their care plan.

This approach allowed CoordinateCare to work within existing hospital IT ecosystems while creating value through coordination and navigation. Their platform effectively functions as an intelligent layer atop existing systems rather than attempting to replace them—a more efficient approach than building or managing redundant EHR functionality. In this case, it would not make sense to directly build or manage any EHR-related functionality.

When This Approach Makes Sense

The middleware approach works best when:

• Your solution needs to operate across multiple healthcare organizations
• Replacing existing EHRs isn’t feasible or necessary
• Data aggregation and normalization are central to your value proposition
• Your focus is on workflows that span organizational boundaries
• You have strong technical resources to manage a more complex event-driven back-end architecture
• You need to work within established healthcare IT ecosystems

Decision Framework: Determine Your Optimal Hybrid Approach

With three viable hybrid strategies, how do you choose the best path for your specific startup? Consider these five key factors:

1. Clinical Workflow Differentiation. Assess how much your clinical workflows differ from standard practice:

• Minimal difference: Extending an existing EHR is likely sufficient
• Moderate difference: A modular approach provides necessary flexibility
• Substantial difference: Building custom components with middleware integration may be required

2. Technical Resources and Healthcare Infrastructure Expertise. Evaluate your team’s capabilities:

• Limited healthtech expertise: Start with an existing EHR and build extensions on top of it
• Strong application development, limited healthcare experience: Go with a modular approach that comes with vendor support
• Deep technical, strong healthcare expertise: Any approach is viable; choose based on other factors

3. Time to Market. Consider your launch constraints:

• Need to launch in 3-6 months: Extending an existing EHR is the fastest path
• 6-12 month timeline: The modular/headless approach is feasible, assuming focused execution
• 12+ months available: Any approach can work; optimize for long-term strategy

4. Investment Allocation Strategy. Map your approach to your funding and resource allocation priorities:

• Pre-Seed/Seed stage: Start with extending an existing EHR to maximize runway
• Series A: Consider modular approaches as you differentiate your product
• Series B and beyond: More extensive customization through any hybrid approach is feasible

5. Integration Requirements. Assess your ecosystem needs:

• Standalone solution: Any approach works; choose based on other factors.
• Integration with specific systems: Select approach based on those integration points.
• Broad ecosystem integration: Middleware approach offers maximum flexibility.

Common Implementation Challenges and How to Overcome Them

Even with a thoughtful hybrid approach, implementation challenges will arise. Here are common hurdles we’ve observed while working with healthtech startups:

API Limitations

Many EHR vendors advertise robust APIs, but in practice, you will encounter limitations with data access, rate limits or functionality gaps. Before committing to an approach, thoroughly test vendor APIs with proof-of-concept integrations, and do a lightweight forecast analysis of how many users and traffic you are expecting in the near and medium-terms. We have had at least one client decide to change their approach after realizing how expensive some free or “low-cost” EHR plans get for typical API access.

Data Synchronization Complexity

Maintaining consistent data across multiple systems presents significant challenges. Define clear ownership boundaries for each data element and implement robust error handling and reconciliation processes. We find that it helps to explicitly map out where each element lives and who owns it. Contact us for a template to get you started. 

User Experience Fragmentation

Maintaining a cohesive user experience while building on top of existing systems requires thoughtful design and integration. Invest in creating and documenting design systems and consistent interaction patterns across your entire platform.

Regulatory Compliance Gaps

Hybrid approaches can create risky compliance ambiguities—particularly around data security and audit trails. Map all PHI flows across your architecture and ensure comprehensive compliance coverage.

How APrime Can Help with Your EHR Strategy

At APrime Technology, we specialize in helping healthtech startups navigate the complex EHR landscape. Our team brings decades of combined experience in healthcare technology, having successfully delivered solutions across all three hybrid approaches described in this article.

Our Expertise

We offer end-to-end support for healthtech companies at all stages:

1. Strategic Assessment: We help you determine the optimal position on the build-buy spectrum based on your specific clinical model, technical resources, and business goals.
2. Vendor Selection: Our team has worked with the most commonly used EHR and integration platforms and can guide you through the evaluation and selection process.
3. Architecture Design: We create robust technical architectures that balance compliance requirements with your unique innovations.
4. World-Class Engineering Talent: From development to integration and deployment, our Senior Software Engineers bring the technical expertise to bring your vision to life.

Success Stories

We’ve helped numerous healthtech startups implement successful hybrid EHR strategies. Visit our Case Studies page, where we showcase examples across various specialties and care models, including virtual primary care, mental health platforms, and care coordination solutions similar to those described in our hypothetical examples.

Looking Ahead: Future Articles in This Series

This article is part of our comprehensive EHR strategy series. In future installments, we plan to explore:

1. Audit Your Current Tech Stack: A practical guide to assessing your existing technology and infrastructure before embarking on EHR implementation. We’ll provide frameworks to evaluate your current systems, identify integration points, and uncover potential technical debt that might impact your recommended approach.
2. Maintenance and Long-Term Considerations: Beyond initial implementation, we’ll explore the ongoing costs, maintenance requirements, and evolution strategies for your hybrid EHR solution. We plan to dive into the technical infrastructure needed to support your hybrid EHR solution, including cloud architecture considerations, DevOps practices, and cost management strategies.
3. Implementation Readiness Toolkit: We’ll share practical worksheets and planning frameworks to help you prepare for a successful hybrid EHR implementation. This toolkit will guide technical and non-technical stakeholders (such as Product Managers, Software Engineers, and Data Analysts) through the preparation process with actionable steps and readiness checklists.
4. Scale Your EHR Strategy: As your company grows from early-stage to established player, your EHR needs will evolve. We’ll examine how to design flexible architectures that scale with your business, when to revisit your position on the build-buy spectrum, and strategies for managing the transition between different approaches.

To learn more about APrime and be kept in the loop on future articles in this series, follow us on LinkedIn, send us an email at hello@aprime.io or schedule a consultation with our founders.

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Footnotes

1. The three example companies used in this article, MediPrime, MindCare and CoordinateCare, are fictional composites of current and former APrime Technology clients. ↩︎
2. Here, we use interoperability to mean the capability of custom applications to seamlessly share data and function smoothly with multiple existing EHR systems through standardized interfaces. 
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3. An integration platform is middleware technology that provides standardized connectivity between your applications and multiple EHR and other systems. ↩︎