During the first day of the HIMSS18 conference in Las Vegas, national HIT leaders discussed the current drivers advancing interoperability in healthcare, and debated whether a great leap forward, or incremental steps, represents the best way forward.
Opening the HIMSS (Healthcare Information and Management Systems Society)/SHIEC (Strategic Health Information Exchange Collaborative) Interoperability and HIE Symposium on Monday morning was Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative, who also is a project lead of the HL7 Argonaut Project and on the board of directors of The Sequoia Project, an organization working to advance interoperable nationwide health information exchange. Joining Tripathi was Ruben Amarasingham, M.D., president and CEO of Pieces Technologies Inc., a clinical artificial intelligence company.
During the morning keynote panel discussion, which was moderated by Jess Kahn with McKinsey and Company, Tripathi and Amarasingham discussed what the end goals for interoperability should be, as well as the business drivers and current efforts to advance progress on interoperability.
Conversely, during the closing keynote session for the HIMSS/SHIEC interoperability and HIE symposium, Aneesh Chopra, president of CareJourney, (formerly NavHealth), an analytics company, and Christopher Ross, Mayo Clinic’s CIO, had a lively debate about the best way to advance sustained interoperability—a great leap forward or incrementalism.
To kick off the morning session, Kahn noted that interoperable health records are still not one of the basic tools of healthcare and asked the panelists what they saw as the ultimate goal for interoperability.
Tripathi noted that until about five years ago, there was not widespread use of electronic health records (EHRs) in the healthcare industry. “It wasn’t until 2013 that we had about 50 percent of providers, hospitals and eligible professionals using EHRs. You can’t have real interoperability until most people have the ability to electronically document and exchange with each other. We started at a very low level, so we’re doing pretty well compared to other industries. Our end goal? We will never really have an end state; it will never be, ‘We got interoperability and its done.’ We’re always going to be moving the goal line,” he said.
He continued, saying he asked a friend who is a physician, “If we had a nationwide system where most providers, 80 percent of providers, had the ability to securely send any EHR (electronic health record) to most other providers and had the ability to securely request and retrieve a medical record, would you consider that nationwide interoperability? She said yes,” he said. “In the next two to three years, because of efforts by CareQuality, we are going to be roughly there.”
He added, “I’m not saying it will solve every use case; it’s important to have realistic expectations. There are significant weight points along the way, and the first one is just here on the horizon through current efforts.”
Amarasingham says he sees the healthcare industry moving toward a more consumer-centric version of interoperability with the end goal of giving patients and end users control of the data. However, he noted that the next stage would be semantic interoperability. He also said he was excited by the entrance of Apple and other consumer-based companies into healthcare, and the potential for these companies to adopt the FHIR (Fast Healthcare Interoperability Resource)-based standard.
“I think one of the challenges for consumers has been, it’s difficult to get their records and incredibly difficult to store it and interpret it; they don’t have the semantic part. If you have 20 million phones that people can say, ‘I want my EHR,’ then press a button and get it, then there is a technological way to keep the data, and then you can have AI (artificial intelligence) systems running on the phones to interpret the data for them. That’s a total change in the power of consumers. That is creating a frictionless environment,” he said.
And, he added, “I predict it to be a milestone event. Soon mobile devices can request electronic medical records.”
Discussing the business drivers, Tripathi says value-based purchasing, in the near term, presented the best use case for interoperability as it relates to sustainability and value. “We’ve seen in just the customer base we have, organizations turn on a dime as soon as they sign an ACO (accountable care organization) contract. We get phone calls from newly launched ACOs, they want to build a ADT (admit, discharge and transfer) event notification service, they are motivated by value-based purchasing.”
Amarasingham agreed, noting that value-based contracts, which have a significant emphasis on care coordination, are one of the most manifest use cases for interoperability. “I’m encouraged by the continued movement in the government to focus on things like accountable health communities and it’s being recognized that health is not just a product of clinical care. That’s going to be significant for interoperability.”
When discussing the players in the market who have the most leverage to advance interoperability, Tripathi noted there are two big levers—EHR vendors and the federal government. “The EHR vendors, that’s where a lot of concentration is. With the top 10 EHR vendors, you’ve got 95 percent of the market right there. With the nationwide networks that are formed, CareQuality and CommonWell, the driver of that was the vendors getting together,” he said, and added, “The federal government is big in every market. Medicare and Medicaid are big in every state, and they drive the market. With the VA-DoD (U.S. Department of Veterans Affairs and the Department of Defense) project, they are leaning forward on interoperability and APIs.”
Amarasingham noted that new entrants into the market, such as Apple, will be market drivers, as these companies have not been faced with the same market forces. “With these large technology firms, whose goal is to primarily expand their market base by expanding consumer options, that’s going to cause rapid interoperability,” he said.
As part of the interoperability journey, the healthcare industry is constantly exploring new standards and opportunities for achieving industry-wide information exchange, such as the FHIR standard, APIs (application programming interfaces) and trusted frameworks.
“FHIR is huge, in the short term and long term,” Tripathi said. “What’s important about FHIR? One, it is a data level standard, as opposed to a document standard. So, with APIs, just give me that description or allergy, don’t just send me CCD-As. Second point, it is a restful API. The developers that we want to bring into healthcare are now jumping in, and they can jump on and develop against the Argonaut implementation guide. Apple is a great example. They are implementing the Argonaut implementation guide.”
Tripathi continued, “Trusted frameworks are huge. A network, in the internet economy, is about defining the rules of governance. Networks allow us to say what are common business issues we want to solve. One of the barriers on the consumer API side, is that we have APIs, but unless we have trusted frameworks, it’s still going to take us a while to get there.”
Kahn also asked Tripathi about the hype around blockchain in all this work. “If we started from scratch, we would have used blockchain, but it doesn’t solve any problems that aren’t already being solved.”
Advancing Interoperability – Great Leap Forward or Incremental Steps?
During the closing keynote, Chopra and Ross debated the way forward to advance nationwide interoperability. Chopra, who served as the first Chief Technology Officer at the White House under former President Barack Obama, said, “The great leap forward, in my view, has less to do with engineering, technology and specifications, and it’s actually more of a mindset great leap, it’s a culture change. By far, the policy foundation on which we built interoperability was on the HIPAA authorization. The other pathway is the individual’s right to access. The great leap forward to me is operationalizing information sharing or interoperability powered by individuals’ right of access. So, the mindset needs to be ‘Let’s rebuild the architecture on patients’ right of access’,” he said.
Ross countered that the argument against taking a great leap forward is the risk of unintended consequences. “If you look at the interoperability statistics, Direct says there has been 170 million health data exchange transactions, that’s a great number, but 6 billion faxes were also sent. We are not there yet. We want to go faster, but the question is, can we have the full liquidity of data and still preserve HIPAA and the underlying sense of privacy and security of data? I’m not sure we have figured out how to do both,” he said.
Ross added, “We live in a world not just of cyber crime, but also of inappropriate access. If we look at the horizon, things like blockchain could be one way to potentially do replicability, but that’s 10 years out. Our pathway from here to there, if we don’t want to run roughshod over HIPAA, to me, that is the core argument for incrementalism.”
There are substantial commercial interests in healthcare data to drive clinical insights, improve care and to develop new drugs, Ross noted. “How do we pressure test various regimes that will allow us to confidently allow these pathways from my health system or individual pediatrician to the patient or designated destination to make sure that organizations aren’t using data for inappropriate uses?”
Many interoperability efforts, to date, such as Direct exchange, have not yet led to nationwide interoperability and there remains a lot of friction in data exchange, both Ross and Chopra agreed.
“No one thought about the consumer in that roll out of the interoperability strategy, and the lack of understanding and awareness on how it works for consumers gives us an opportunity to leap frog forward,” Chopra said.