Micky Tripathi, Ph.D., the founding president and CEO of the Waltham-based Massachusetts eHealth Collaborative (MAeHC), has been active in healthcare industry thought leadership for many years, in a wide variety of areas, including strategic planning and consulting, policy advisement, and health information exchange (HIE) development, among others.  Not long after Farzad Mostashari, M.D. announced that he would be stepping down this autumn from his position as National Coordinator for Health Information Technology, Tripathi sat down for a conversation with HCI Editor-in-Chief Mark Hagland, to offer his perspectives both on what might be next for the Office of the National Coordinator for Health IT (ONC) specifically, what the meaningful use process under the HITECH (Health Information Technology for Economic and Clinical Health) Act, and how the new healthcare—the healthcare system’s shift towards accountable care, population health, patient-centered medical homes, value-based purchasing, and the like—is shaping up at this critical moment in the history of the U.S. healthcare system. Below are excerpts from that interview.

Given the announcement of Dr. Mostashari’s imminent departure from ONC this fall, what might and should happen at ONC next, in your view?

Well, just to be clear, it’s not as though I have a deep inside track to information; but I do spend a lot of time with the advisory groups at the ONC. I think right now, from what I can see, is that what should happen probably will happen, for the most part. There are only two years left in the Obama administration, and even if a Democrat succeeds President Obama, there will most likely be turnover at the agency. Now, Farzad’s position is not a congressionally appointed position. But the political scenario probably narrows the field a bit. And the fact that the meaningful use train has left the station and is moving down the tracks, that fact suggests that you’d want someone pretty familiar with the meaningful use process, who can pick up the remainder of the Stage 2 work and pick up with Stage 3.

Micky Tripathi

Does that mean you believe that Dr. Mostashari’s successor will or should be an ONC insider?

Yes, I’m going to suggest that it probably will be and should be an “insider,” but I would suggest that the concept of “insider” would encompass the HIT Policy Committee and Standards Committee, and others who advise those committees or might be a part of some of the other committees, or maybe the think tanks. There is an establishment of people who have been very involved in or have been close to this. Not to disparage anyone who’s not been a part of the process, and it’s always good to bring in good ideas, but I’m not sure that’s the task. Someone coming in will have to be able to pick up the process and guide it to completion. My personal thought is that it should also be a physician, not necessarily because physicians are more qualified than anyone, but in terms of the representation to the public.

And in terms of the advocacy part of the role, per physicians in practice in this country?

Yes, the sense that whoever’s in charge understands physicians’ concerns. I don’t think it necessarily translates into a difference in how they operate on the ground, but this is about change, and the physician industry is a craft industry of very bright people, but people who are trained institutionally and academically to think and act independently, and it takes a lot of advocacy to change that. And I can say that because both of my parents are physicians. And that’s partly what makes it so complex.

Does meaningful use feel on track to you right now as a process?

Within the environmental constraints that all of us face in the industry at large, I think it’s very much on track. But let me explain why I framed it that way. If you think conceptually about what meaningful use was supposed to do, it was supposed to first get people onto [clinical information] systems, and then get them to use those systems, and then get them to use those systems to be a vehicle for changing care outcomes. So it seems to me that if you look at the adoption numbers of electronic medical records, they’re phenomenal. And even the most cynical people have to look at that. And yes, there’s going to be churn of vendor selection and implementation. But I don’t think anyone can look at an industry like this one, especially such a guild-based industry as this one, and not concede that MU has been successful in terms of adoption. 

Now, in terms of the other issues—calls for the extension of Stage 2 or the delay of Stage 3—you’re seeing a lot of industry groups asking for relief in some way. And I’m very sympathetic to those calls because of all of the various things hitting the providers and industry at the same time. If we were just talking about meaningful use, I would say we should all just say, let’s just keep the pedal to the metal and keep going forward. And given the way the payment structure is, the more you extend it, the more it dilutes the outcomes. But ICD-10 is coming now, and that’s a big lift. We’re creating a statewide testing platform here in Massachusetts with the Massachusetts Health Data Consortium, with over 150 organizations. And rather than every health plan having to test with every provider on a paired basis, which is unbelievably inefficient, is there maybe a better way? Why wouldn’t you all pool your resources for this? Just think about Blue Cross having to test with every provider organization in the state and then Harvard Pilgrim and Tufts doing the same thing. But my point is, that’s a huge lift. And now you’ve got accountable care and value-based purchasing now changing the fundamental paradigms of how healthcare is being paid.

So meaningful use is sort of coming at the same time as everything else; and I think it would make sense to create some accommodations.

So what would your recommendation be, around that?

I don’t have a specific recommendation, and I haven’t looked, frankly, at what the impact would be of specific proposals like extending Stage 2 or delaying Stage 3. But I am very sympathetic to the need to perhaps consider that, because of these other factors. Perhaps we could extend Stage 2, keeping things moving forward while giving people a little bit more time in Stage 2, while keeping the Stage 3 timeline as it is, so that those who are ready can keep going.

Looking at the shift to the new healthcare, what are your thoughts? In your view, how are things moving forward right now?

I’m actually amazed at how fast things are moving. I would love to say that this is just how I predicted it three years ago, but in fact, it’s gone so much faster than I’d ever envisioned. I’m just amazed at how deeply the concepts of accountable care and value-based purchasing have already seeped into the industry. And so even leaders of community hospitals that aren’t actually yet in the pertinent risk-based contracts know what’s coming. That’s pretty amazing. And it’s also pretty amazing in that it’s hard to find a provider who doesn’t know where they are on the spectrum of EHR [electronic health record] development. Everyone has thought about it, and organizations either already have one of those, or are about to implement one.  And that’s somewhat true of HIE, too. And in terms of HIE, I’ve been amazed… I’m hard-pressed to think of a conversation I’ve had with any hospital where they weren’t thinking about HIE, whether they’re funding something or working towards it. If they don’t have a strategy, they’re in a high degree of angst about it.

So how far accountable care and patient-centered medical home concepts have penetrated into the industry, and how far the awareness of the need for EHR and HIE have come, those are all amazing. And HIE is happening faster than I would have thought, even a few years ago. There was this sense that it was swimming upstream, that it was a fight against the market. Now, both the good and bad news are that HIE is demand-driven and responding to the market. The problem is that the technologies are all so different. Just yesterday, I was looking at DocBookMD, they’re promoting an app to all the medical societies in the country. I’m not promoting them at all, but someone told me that 200 members of one medical society have signed up for this. And it involves taking a picture of an image. And you could do a screen shot of a problem list, so hey, wow.

My only point is that it’s now incredibly decentralized, and because technology is advancing so rapidly and putting more and more power into the hands of the individual, health information exchange is happening all over the map, but it’s a little bit chaotic. So the benefit of it is that it’s organically driven, and people really want it; the bad thing is that it’s quite chaotic The older conception of health information exchange was that it should be a bit more organized and you could get public health surveillance out of it. If you use DocBookMD and then you don’t want to participate in a formal HIE, you’re not going to get public health surveillance out of it.

And look at this: the first iPad come out in March or April of 2010, version 1; and now we’re just a little over three years into that era.

Do you think that physicians now understand that this shift is taking place towards the new healthcare?

Yes, I think they do. Well, looking at the older cohort—my mother still practices, and my father is now retired—some of them just want to get out now. But there is a whole group who kind of get the message and are grudgingly accepting that they have to use EMRs, and grudgingly accepting the whole patient engagement thing. And I think in a way, this is just a transitional issue, because generationally, the younger doctors are all on Facebook, and they don’t even understand what the issue is. What’s scary to them is that they’re so used to having technology immediately available in their hands that they don’t fully appreciate the PHI security issue, that your iPhone app may not be secure enough!

Do CIOs as a group understand where things are headed, in your perspective?

Yes, I think that CIOs have some of the most thankless jobs today, even though they’re fascinating jobs, but on the other hand, they are the ones who are out in front with a lot of risk. You’ve got the tension that a CIO feels over ICD-10 and 5010, but you also need to satisfy the docs and satisfy the BYOD demand, and the docs need single sign-on for everything, and by the way, if we have a single breach, you are in deep, deep trouble, and by the way, we’re cutting your budget and this needs to get done in the next year. And by the way, we’re competing for qualified IT people with Epic [the Verona, Wis.-based Epic Systems Corporation], and we’re only able to pay about three-quarters of what Epic pays. I think CIOs get it; it’s more the constraints and the priority issues.

Many people in healthcare have been expressing concern about the growing dominance of Epic in the industry, as a potential policy problem, while others believe the concerns are overblown. What are your thoughts?

I think it’s a legitimate concern whenever any single vendor becomes dominant, per monopoly and pricing power issues; there’s certainly something to that concern, and I’d think there’s probably a concern for Epic as well. And I think that most companies agree that competition makes them better. That said, one of the issues we’ve had in healthcare that makes it somewhat different from other industries, is that we have had extreme fragmentation both on the supply and demand sides. Look at what happened in retailing when Wal-Mart and Target started standardizing, or in the airline industry when American Airlines got Sabre; or in banking, with NICE, and such. So in some ways, there’s a certain amount of standardization that needs to happen in this industry, and even consolidation, and we need some of that.

The fact that I can send an Outlook Invite to someone in India, and they can receive that Invite and respond to it, is kind of amazing, right? So there’s power in that. And part of why Epic has done well is that that they’ve standardized implementation somewhat as a craft; and it reflects some of the frustration that a lot of organizations have had with this interoperability mire. And that kind of thing has happened in some other industries.

That’s what banking did, of course. But some people are feeling some ambivalence around this situation in healthcare IT.

Yes, and ambivalence is healthy; there are some good and bad aspects involved. And with CommonWell, there is some genuinely good intent, knowing some of the people involved. But there is also the reactive side of it which is, Epic is eating our lunch, and the rest of us had better get together so that we collectively can survive, so that’s a part of that reaction as well. So in some ways the market is kind of addressing that. But one of the interesting things of this to me is, if you look at other industries like airlines, banking, and retail, who was it that did the consolidation? Either the suppliers or the demanders/consumers. In this case, it was the vendors. The providers are so fragmented that they can’t consolidate; the same thing with the consumers. So it’s the vendors. And that’s kind of odd in a way, right? In the airline industry, it was American Airlines. And in the banking industry, it was the banks who told the vendors they wanted this thing. But here, the vendors decided they would  get together and standardize.