On Monday morning, Donald Rucker, M.D., the National Coordinator for Health IT, spoke broadly on issues around the interoperability and usability of data, access to data on the part of consumers and payers, and the intersection of health information exchange (HIE) with those issues, in the opening keynote address at the SHIEC Annual Conference, being held at the Crowne Plaza Indianapolis Downtown Union Station in downtown Indianapolis, and sponsored by SHIEC, the Strategic Health Information Exchange Collaborative.
Dr. Rucker, who became National Coordinator in early spring of this year, has spoken frequently about the challenges and opportunities around interoperability, since joining the Office of the National Coordinator (ONC), a division of the Department of Health and Human Services (HHS), at the end of March.
To some extent, Dr. Rucker on Monday reiterated some of the points he had made on July 24, when he appeared at the ONC’s first sponsored meeting around the development of a trusted framework for data exchange. As Healthcare Informatics Managing Editor Rajiv Leventhal noted in a report on the July 24 meeting, “During the session, Rucker outlined three important outcomes for a trusted exchange framework... First, patients can access their health information electronically without any special effort. Second, providers and organizations accountable for managing the health of populations can receive necessary and appropriate information on a group of individuals without having to access one record at a time, which would allow them to analyze population health trends, outcomes, and costs; identify at-risk populations; and track progress on quality improvement initiatives. Third, the health IT community should have open and accessible application programming interfaces [APIs] to encourage entrepreneurial, user-focused innovation to make health information more accessible and to improve electronic health record (EHR) usability.”
At the SHIEC Conference this morning, Rucker reiterated some of the main points he had made last month. And he asked the question, “How do we get our hands around the challenges of interoperability? It’s the exact same challenges you face every day,” he said. “Messaging, patient-centered medical homes, are all wonderful things. As ONC looks at use cases on interoperability,” he said, we’ve sort of come down to three use cases. A core foundation for these three use cases is smooth provider-to-provider interactions. Meanwhile, the first use case is electronic access to patients’ records by patients. What Congress had in mind is, you can point an app at a provider, and get the data. You already have the legal right to get your records in 30 days, under HIPAA [the Health Insurance Portability and Accountability Act of 1996]. So let’s harness those powerful computers to collect our medical data. That allows us to shop for care and better understand the care we’re getting. That’s direct access.”
Donald Rucker, M.D.
Rucker went on to say that “The second use case is really about sort of the broader interoperability en masse. It’s sort of getting the bulk of data” to be available to all appropriate owners and users of that data. “First and foremost, on a practical level, are the payers” of healthcare—the federal government and state governments and health insurers and employers, he said. Appropriately making data available supports the development of the concept of the learning healthcare system, supports research, and supports clinical registries, Rucker said, with that last element mandated under the 21st Century CURES Act, passed by Congress and signed into law by President Barack Obama on Dec. 13, 2016. Among the diverse provisions of the law are ones that encourage the interoperability of electronic health records (EHRs) and patient access to health data, and discourage information-blocking. Healthcare IT leaders have largely been very supportive of that law.
Encouragement for Open APIs
One element in all of this that Dr. Rucker strongly encouraged was the development of open application programming interfaces, or APIs. “The third use case,” he said Monday morning, “is around how we define an open API.” He referenced an app on his smartphone that had helped him locate the entrance to the conference center at the Crowne Plaza, which is somewhat in terms of the view of it from the street. “All I had to do was to look at my map on my smartphone,” he said of the experience. “That’s a wonderful example of an open API. You can go to Google Maps and it will feed you back a map. Those types of things. And it’s that kind of thing that Congress was thinking about” when both houses of Congress passed the 21st Century Cures Act last year, he emphasized. “So,” he said, “we have to think about open APIs in two very specific ways. One, what does that open API look like at the vendor level? And then, what does it look like at the provider level?” Data and IT security will be very important in protecting protected health information (PHI) going forward, he noted, but he said that that was something that could be accomplished.
And, “In terms of trusted frameworks—at the end of the day, patients need access to the data, the people who are paying for the care need access, and the providers obviously need access,” Rucker said. “Some of these regional exchanges, identifying patients who are getting care [across states]—we’d like to have some of those types of services available in ways that don’t create more data monopolies or mandatory toll gates.” Indeed, he noted, “As we move into these value-based healthcare payment and delivery system models, some of these [data protection] lines that were originally articulated in the 1990s, may get in the way. Any indication anyone might want to revisit that? Providers are not only providers now, many are now at risk in contracts with private insurers and with self-insured employers. So there’s a lot of sorting out to do” in terms of the management of data and information, he said. But inevitably, he reassured his audience that federal healthcare authorities will maintain rigor in supporting data and IT security and privacy in U.S. healthcare.
And, Dr. Rucker concluded, “Healthcare data exchange will definitely be involved” in the shift towards a value-based healthcare system. “Even just notifications of status changes for patients can be very valuable.” In concluding his keynote, Rucker encouraged HIE leaders to continue to push ahead, despite all the challenges, noting that data exchange will be a core element in the emerging healthcare system, as all stakeholder groups in healthcare work to improve the system for everyone.
Meanwhile, following his keynote address, Dr. Rucker spoke exclusively with Healthcare Informatics about the current moment in healthcare. Below are excerpts from that interview.
Dr. Rucker, it was great to hear your keynote address just now here at the SHIEC Conference. With regard to our core audience at Healthcare Informatics, where should CIOs and CMIOs be directing their core energies right now, per what you’ve just shared with the audience here?
Nothing’s easy here, but the easiest way to think about this is, what was the intent of Congress, in terms of the CURES Act? We’ve done a lot of stuff around healthcare IT over the decades, but what’s left to do in 2017? On the interoperability side, it seems to me that we’ve done a lot of hardwired stuff with point-to-point [clinician and patient care organization communication], right? But we have to think about this a little bit in the way that he modern software industry looks at it. I think that open APIs are really the way to go here, and what they are really saying is, and CCDA [consolidated clinical design architecture] is part of this, and what they’re saying is, let’s encapsulate the data into a payload, and let’s put a public-facing address onto that door, if you will. And that doesn’t mean the door is unlocked: there’s always going to be a security architecture around all that. But let’s find a public-facing way to get at the data.
That’s the intent of Congress. A number of parties have rights to the data under law and contract law and HIPAA, and so on. And some of those rights go beyond simple provider-to-provider connections. Historically, people have focused on the provider next door. And in terms of the original use case for interoperability, that made sense. But Congress is saying, there’s more to it. And it’s worth pointing out, they didn’t say open APIs for some; it’s fairly broad. And they’re trying to include not just the providers, but also the patients and the payers; registries are one use case that’s important.
And it speaks to the ongoing shift into value-based purchasing and population health, correct?
Yes, it absolutely speaks to value-based purchasing and population health; we just need to get more sophisticated about what we’re doing in general. And the tools are evolving forward. I’m going to look at some of the vendors here [at the conference], and see what the latest solutions are. So I think if you’re a CIO, or even a [physician], you sort of have to realize that this data extends beyond your organization. And this is both true at an institutional level and an individual level, with things like the OpenNotes movement. It really is a shared ownership [over the patient record, between clinicians and patients]. And we just have to be mindful that it is a shared ownership, with a number of rights that have until now not been practical to exercise by others, and the law is changing to accommodate those rights. Those people always had the rights to access data, before HIPAA, under HIPAA. But it hasn’t been easy for anybody [to achieve access]. What’s the fuel for all of this? The fuel is that this is a very expensive, very opaque healthcare system, where people don’t know what they’re getting for what they’re paying for.
So when you look at value-based purchasing, or many of the provisions of the Cures Act, or the extraordinary politics around healthcare reform, people are collectively—they’d like to know more about what they’re getting. So we need to have a better understanding of it. And so that’s the economic element; and then I believe that information can transform healthcare; we’ve seen this in industry after industry after industry. Why shouldn’t that be true in healthcare?”
Will there be a final piece of meaningful use? Our readers in the hospital sector are really wondering.
Meaningful use has been a process under the HITECH [Health Information Technology for Economic and Clinical Health Act] law, and is mandated by the HITECH Act. If you look at congressional intent, your guess is as good as mine. This is an area where you saw with the MACRA [Medicare Access and CHIP Reauthorization Act of 2015] law, Congress has shown a willingness to revisit this, and I think there’s an ongoing evolution in terms of how we use this technology. It’s sort of hard to imagine that meaningful use evolution wouldn’t be part of the broader payment and technology r evolution. I don’t have anything to say about specifics. But for your readers, we expect this to evolve in the broader current of what we’re paying for, in terms of value and policies.
Can you speak at all to the question of whether there will be any substantive Stage 3 for hospitals?
If you look at the law, there’s a provision that the requirements should do something like tighten up—but there’s no specific timetable around that. I think you have to look at meaningful use in the broader context of how Congress wants to pay for HC. We’ve seen changes under MACRA.
What I can say is that our priorities are interoperability and what’s under the Cures Act and burden reduction. You can parse that. Meanwhile, I think the thing for your readers to consider is that this sits in the broader context of how we pay for HC, and the broader transition of how we get value from it. Meaningful use was designed to capture value for healthcare payments; there’s a broader national evaluation of how we capture value in HC payments; and ONC will be both listening to what Congress says, and participating with everyone else that conversation.
In the end, this is all about value in healthcare, correct?
Yes, that’s correct. The challenge around value is that we’ve moved purchasing in healthcare from the free market and free-market equilibrium where consumers and producers agree on price, to a situation where we now have proxy consumers, which is the federal government and all the payers, who are trying to imagine what the consumer would pay for. And we’re trying to get the consumer back into the equation. The biggest way to do that, of course, is high-deductible health plans and health savings accounts; but one of the ways we’re trying to do this is through consumer access to data liquidity. And payers are consumers, too; and they need access to this data. So it really is broader than simply provider-to-provider data-sharing.