Outgoing DirectTrust CEO David Kibbe, M.D., Talks About FHIR, Blockchain, TEFCA and Direct Standards Development | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Outgoing DirectTrust CEO David Kibbe, M.D., Talks About FHIR, Blockchain, TEFCA and Direct Standards Development

June 19, 2018
by David Raths
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Three potential applicants for TEFCA Recognized Coordinating Entity express interest in DirectTrust identity credentialing, access management
David Kibbe, M.D.

Even though he is planning to step down this year as president and CEO of DirectTrust, the nonprofit organization that support health information exchange via the Direct message protocols, David Kibbe, M.D., has plenty of opinions to share about DirectTrust’s future, ONC and TEFCA, and interoperability’s role in value-based care. In a wide-ranging interview with Healthcare Informatics, Kibbe looked back over his time leading DirectTrust and described its current work to become an accredited standards development organization.  

The use of Direct, largely to replace the fax machine in referral management and transitions of care, continues to grow. DirectTrust said that there were 47.8 million health data exchange transactions in the first quarter of 2018 – a 90 percent increase from the same time period in 2017. Kibbe said that growth in the DirectTrust network    over the past four years is faster than the growth in Facebook accounts in its first four years. “Most people find that an amazing statistic,” he said.

The standard works well and is slowly but surely replacing the fax and other paper courier and telephonic communications in healthcare, but there is still a lot more room for growth, he said. “There were 9 billion faxes in healthcare industry alone in 2017, he said. “The 200 million transactions we think we will achieve in 2018 is a huge growth rate for an early standard. It eclipses what happened with e-prescribing, but we still have a long way to go.”

The use of Direct seems to vary quite a bit by region. “Where there is competition in healthcare and multiple EHR vendors operating in the same community, Direct exchange has been more easily adopted,” Kibbe said. There are places where a particular EHR vendor is so dominant that they don’t need to use Direct very much. But even in markets where Epic has 50 percent of the market, the other 50 percent are on some other EHR. “The expectation that Epic customers have for CareEverywhere to work has also meant they want interoperability with others using athenaheatlh or Cerner or other EHRs,” he said.

ONC and TEFCA

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I asked Kibbe whether he thought the Office of the National Coordinator for Health IT (ONC) had done a good job of fostering and promoting Direct, given that it wasn’t really mentioned in the draft TEFCA document. “We have a strong relationship with ONC. We have been partners and we have meetings with them every month, but ONC has not been particularly adept at juggling three or four balls at the same time,” he said. Initially, they pushed Direct exchange hard, and then got onto FHIR, and it became their focus. “We have had a little bit of benign neglect. But now we are working with them on an extension of our trust framework to FHIR. We are coming back into favor, if you will, because of developing that piece that can extend to other technologies.”

Regarding TEFCA, Kibbe called it “a bit of a Rorschach test.”

“It is hard to understand what the Trusted Exchange Framework (TEF) is,” he said. “I think we are going to have to wait until we see an RFI or funding opportunity for the recognized coordinating entity (RCE). I know they were a bit taken aback by the scale and consistency of the criticism for the whole TEF. People were worried that existing trusted exchange frameworks and agreements they have with different parties could be disrupted by something that was top down. That was not the intention at all of ONC. I think it took them aback that they were perceived as being heavy-handed. I think it is going to go much slower than most people thought. For one thing, ONC’s budget has been drastically reduced.”

He said it might not be a bad thing that Direct exchange and the DirectTrust network were left out of TEFCA. “They said, ‘Your community is working fine; we don’t need to include your trust framework because you are getting the job done. We don’t see a purpose in meddling in that. The challenge is FHIR-based query.’”

Potential RCEs Look to DirectTrust

He said one unintended consequence of the TEF that has been beneficial to DirectTrust and its community is that the issue of identity and the role of certificate-based public key infrastructure (PKI), and scaling of trust relationships has been put front and center. “We are talking with three parties that want to be in the running to be the RCE,” he said, “and they all want the same thing from DirectTrust: the PKI-based identity credentialing and access management component put in place to support Direct exchange. We are now pivoting to support trusted exchange with other technologies. There is no reason to re-invent that healthcare-tuned set of policies around identity that DirectTrust had to establish.”

FHIR and Blockchain?

Last month I wrote about a webinar in which members of DirectTrust workgroups discussed their efforts to allow for the exchange of FHIR resources using its certificate-based trust framework. I asked Kibbe if that trust framework could be applied to blockchain as well. “Absolutely,” he replied. “I get calls almost every day from someone in the blockchain community who wants to know more about how DirectTrust certificates might be useful to them.” He cautioned that we are in the very early in the blockchain experiment, and not all types of blockchain are the same. The kind that seems to be fitting in healthcare is not public like bitcoin. They are called private, permission-based blockchains. “In those instances, the access to writing to the ledger needs to be highly constrained to only those parties strongly identified with credentials.” That is where the use of DirectTrust certificates and policy infrastructure for identity might play a role, he added.

DirectTrust as a Standards Development Organization

DirectTrust is in the process of becoming accredited as a standards development organization (SDO) by ANSI, the American National Standards Institute. DirectTrust has a lot of the DNA to become accredited, he said. It requires being very transparent, following strict processes and having procedures for dispute resolution. “Although we have not functioned as a formal SDO, we are confident we can make this transition,” he said. The standard itself has been managed by the Direct project, which is pretty loose and consensus-based, he added. “There is nothing wrong with that, but it is not as process-driven and transparent as it needs to be in the future.”

ONC had expressed interest in handing it off, he said, and stakeholders such as the EHR Association wanted to know there is an accredited SDO shepherding the standard and allowing for more people to participate.

New Components to Make a Smart Network

Kibbe expressed excitement about a new component of the Direct standard starting to be put into production. Called the implementation guide expressing context in Direct messaging, it allows for Direct messages to be accompanied by metadata that could be useful for patient matching, for example. It could allow sender and receiver to agree on workflows such that the receiver knows what the information is for, and to whom it goes and what is expected in return.

“This is a way a dumb network gets smart,” he said. “Because it is electronic, the parties can innovate and create these new components of the standard and get smarter and smarter. We will eventually get to where the transactions will be much easier for both parties to handle.”

Looking to the Future

A DirectTrust search committee is interviewing candidates to take Kibbe’s position. I asked him if he was going to retire to his sailboat or keep working on interoperability issues. “I am going to keep my hand in,” he said. “I am talking to people about potential roles in this area. I have a very strong interest in the application of interoperable standards-based health information exchange in value-based care situations. David Brailer famously said there is no business case for interoperability in fee for service. That is still somewhat true. If we had more incentives for holding provider organizations accountable in terms of quality and cost reduction, I think health information exchange would just explode.”

 

 

 

 

 

 

 

 


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New DirectTrust CEO Sees Potential for Applying its Trust Framework in Other Healthcare Contexts

October 15, 2018
by David Raths, Contributing Editor
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Former Cerner exec Scott Stuewe seeks closer relationship with EHR vendors
DirectTrust CEO Scott Stuewe

In July the nonprofit DirectTrust named former Cerner executive Scott Stuewe its new CEO to replace founding CEO Dr. David Kibbe. In a recent interview with Healthcare Informatics, Stuewe spoke about working more closely with EHR vendors and expanded opportunities for his organization’s trust framework.

Stuewe spent 24 years at Cerner, including working on interfacing and systems integration. His last three years there were spent focused on the Commonwell Health Alliance and trying to convince Cerner clients to get more involved, so working on interoperability issues is not new to him.

In fact, the role at DirectTrust seems like a logical next step in his career. “I spent some of the most exciting years of my life working on systems integration efforts,” he said. The Commonwell effort gave him an opportunity to get to know key players in the interoperability space. He also participated in Carequality advisory group, where he got to know people at Epic and other places that had not been active in Commonwell.

I asked Stuewe what he had discovered about the strengths of DirectTrust in his first few months.

“I think what was new to me was the strength of the trust framework as a technical trust framework,” he said. Other interoperability groups have trust frameworks that are legal and policy documents. “Those documents are the bread and butter of what those organizations are about. DirectTrust has this technical trust framework. which is about stretching the highest security mechanism across identity-proofed endpoints, and that is kind of a unique model. That is the advantage of the trust framework that DirectTrust represents – that identity proofing process and technologies associated with it are hardened at a level that really nothing else at its scale can really point to.”

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When I interviewed Dr. Kibbe in June, he spoke about how DirectTrust was working with the Office of the National Coordinator on an extension of its trust framework to FHIR. I asked Stuewe if he saw that as an area with potential.

He replied that it is a huge opportunity for DirectTrust. He said something like SMART on FHIR uses the same technologies that are in use in Facebook and other social media platforms. But higher levels of trust need to be established in healthcare than has been used in social media, where there have been some very large-scale data breaches. “The way the FHIR community has so far imagined that connections will be made is that the end points, that is, the provider organizations, take the responsibility to ensure that the people who are able to get to their data are who they say they are and are appropriate,” Stuewe said. People do all sorts of secure transactions over the internet, but they do so using a public key infrastructure (PKI) of the sort that DirectTrust represents, he added. “I think there is great potential there. We have demonstrated it is doable, but it does require both the caller and receiver to make relatively small accommodations for the certificates that will enable that exchange. That is not the way FHIR has been rolled out so far.”

What are some other areas where DirectTrust needs to make progress?

Stuewe says the organization could make more headway by engaging with the EHR vendors who so far have not been very engaged with DirectTrust. “There are some gaps in features among the EHRs that frankly are the same gaps we saw in query-based exchange in Commonwell. There are usability problems; the way a given feature surfaces in one EHR is so different than another that you can’t even do the same work flow across the two systems.”

He noted the same was true in query-based exchange and it took three years of meetings with the EHR vendors showing each other their user interfaces to make progress. “That is what I believe we can get done in DirectTrust,” he said. “Our clinician work group issued a consensus statement on the features/functions required for Direct to be fully adopted by the clinical community. The problem is we don’t have enough of the EHR players as participating members to really stimulate that conversation. I am eager to reach out and point this out because we are actually not that far from being able to make tremendous headway. In fact, there are a ton of things we can do right now. We are already at 1.7 million addresses and 50 million transactions per quarter. It is really happening. But there are a whole lot of things DirectTrust could do that it can’t right now given the differences in the way the EHRs work.”

Stuewe said that by far the biggest opportunity for DirectTrust is to apply its trust framework in other contexts. “FHIR is one of them, but we look at some other healthcare communication vectors, and believe healthcare communication can be secured by our PKI regardless of what standards or technologies are used for those.”

He added that it would be important to identity-proof the consumer at scale to enable more comfort from provider organizations around the connections people are going to want to make to them. “We believe that has a huge value and I think given the entry of the large consumer-based organizations into the world of healthcare, that is the opportunity we have,” Stuewe explained. “If you combine FHIR, a trust framework and a major consumer player, then that is when you can make a lot of this stuff actually work. I am excited about it.”

 


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VA-DoD Leaders Signal Commitment to Achieving Interoperability, but What Uphill Challenges Will They Face?

October 15, 2018
by Heather Landi, Associate Editor
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"There is no precedent for this level of interoperability in healthcare,” says one industry thought leader
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The U.S. Secretaries of Veterans Affairs (VA) and Defense (DOD) have signaled their commitment to achieving interoperability between the two agencies by implementing a single, seamlessly integrated electronic health record (EHR), according to a joint statement published last week.

VA Secretary Robert Wilkie and Defense Secretary James N. Mattis signed a joint statement Sept. 26 pledging that their two departments will “align their plans, strategies and structures as they roll out a EHR system that will allow VA and DoD to share patient data seamlessly,” according to a press release about the joint statement.

“The Department of Defense and Department of Veterans Affairs are jointly committed to implementing a single, seamlessly integrated electronic health record (EHR) that will accurately and efficiently share health data between our two agencies and ensure health record interoperability with our networks of supporting community healthcare providers,” the joint statement from Wilkie and Mattis states. “It remains a shared vision and mission to provide users with the best possible patient-centered EHR solution and related platforms in support of the lifetime care of our Service members, Veterans, and their families.”

The VA and the DoD are both undertaking massive projects to modernize their EHR systems and both departments plan to standardize on Cerner’s EHR. The hope is that this will provide a more complete longitudinal health record and make the transition from DoD to VA more seamless for active duty, retired personnel and their dependents. Once completed, the project would cover about 18 million people in both the DoD and VA systems.

The VA signed its $10 billion contract with Cerner May 17 to replace VA’s 40-year-old legacy health information system—the Veterans Health Information Systems and Technology Architecture (VistA)—over the next 10 years with the new Cerner system, which is in the pilot phase at DoD.

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DoD began rolling out its EHR modernization project, called Military Health System (MHS) Genesis, in January 2017 at Fairchild Air Force Base and three other pilot sites in Washington State. The DoD EHR overhaul contract, which was awarded in 2015 to Cerner, Leidos and others, is currently valued at $4.3 billion. The new EHR system is expected to be deployed at every military medical facility in phases over the next five years.

“There is no precedent for this level of interoperability in healthcare, but one can hope the DoD-VA effort will drive the evolution of meaningful interoperability forward and benefit everyone,” says Dave Levin, M.D., chief medical officer at Sansoro Health and former chief medical information officer (CMIO) for Cleveland Clinic. Levin has been observing the VA-DoD interoperability efforts and has written several blogs pointing out the critical challenges facing the two agencies in these efforts.

“There is a long-standing need for the VA and the DoD to be on the same information database for service members and veterans. Cerner is a good product. I am hopeful that Cerner’s commitment to the FHIR (Fast Healthcare Interoperability Resources) standard and to process interoperability standards will be revealed to the general community and implemented wholeheartedly, because at the end of the day, it’s not what’s best for VA and DoD, it’s what’s best for veterans and service members as they consume care along their own personal pathways,” says Shane McNamee, M.D., who previously served as the clinical lead for the VA’s Enterprise Health Management Platform (eHMP) effort and also the VHA business lead for the development and deployment of the VA’s Joint Legacy Viewer. He is now the chief medical officer of Cleveland-based software company mdlogix.

In the press release, Wilkie said the joint statement represents “tangible evidence” of VA and DoD’s commitment. “The new EHR system will be interoperable with DoD, while also improving VA’s ability to collaborate and share information with community care providers. This will ease the burden on service members as they transition from military careers and will be supported by multiple medical providers throughout their lives.”

Wilkie also said the new EHR system will give health care providers a full picture of patient medical history and will help to identify Veterans proactively who are at higher risk for issues, such as opioid addiction and suicide, so health care providers can intervene earlier and save lives.

Specifically, the joint statement pledges that VA and DoD will develop an accountability mechanism to coordinate decision-making and oversight. “The importance, magnitude, and overall financial investment of our EHR modernization efforts demand alignment of plans, strategies and structure across the two departments,” the two agency leaders stated in the joint statement. “To this end, DoD and VA will institute an optimal organizational design that prioritizes accountability and effectiveness, while continuing to advance unity, synergy and efficiencies between our two departments.”

VA and DoD will construct a plan of execution that includes a new organizational structure that optimally coordinates clinical and business workflows, operations, data management and technology solutions and a more detailed implementation timeline.

"We are committed to partnering with the VA to support the lifetime care of our service members, Veterans and their families," Mattis said in the press release. "This modern electronic health record will ensure those who serve our nation have quality health care as they transition from service member to Veteran."

An Uphill Battle for Interoperability

Interoperability between the VA and DoD has been a long-standing goal for both agencies, and the past two decades has seen the agencies making strides to achieve interoperability between two separate health IT systems. However, progress on this front has been slowed by both operational and technical challenges.

Back in April 2016, the DoD and VA signed off on achieving one level of interoperability, after the VA implemented its Joint Legacy Viewer (JLV) the previous fall. The JLV is a web-based integrated system that combines electronic health records from both the DoD and the VA, which enables clinicians from both agencies to access health records.

However, as reported by Healthcare Informatics, during a congressional hearing in July 2016, a Government Accountability Office (GAO) official testified that in 2011, DoD and VA announced they would develop one integrated system to replace separate systems, and sidestep many of their previous challenges to achieving interoperability. “However, after two years and at a cost of $560 million, the departments abandoned that plan, saying a separate system with interoperability between them could be achieved faster and at less overall cost,” Valerie Melvin, director of information management and technology resources issues at the GAO, testified at the time.

Melvin said that the VA has been working with the DoD for the past two decades to advance EHR interoperability between the two systems, however, “while the department has made progress, significant IT challenges contributed” to the GAO designating VA as “high risk.”

And, Melvin summarized the GAO’s concerns about the VA’s ongoing modernization efforts. “With regard to EHR interoperability, we have consistently pointed to the troubled path toward achieving this capability. Since 1998, VA has undertaken a patchwork of initiatives with DoD. These efforts have yielded increasing amounts of standardized health data and made an integrated view of data available to clinicians. Nevertheless, a modernized VA EHR that is fully interoperable with DoD system is still years away,” Melvin said during that hearing two years ago.

Fast forward to June 2017 when then-VA Secretary David Shulkin announced that the department plans to replace VistA by adopting the same EHR platform as DoD. Six months later, Shulkin then said that the contracting process was halted due to concerns about interoperability. According to reports, VA leaders’ concerns centered on whether the Cerner EHR would be fully interoperable with private-sector providers who play a key role in the military health system. VA leaders finally signed the Cerner contract this past May.

The Pentagon also has hit some road bumps with its EHR rollout. In January 2018, DoD announced the project would be suspended for eight weeks with the goal to assess the “successes and failures” of the sites where the rollouts had already been deployed. This spring, a Politico report detailed that the first stage of implementations “has been riddled with problems so severe they could have led to patient deaths.” Indeed, some clinicians at one of four pilot centers, Naval Station Bremerton, quit because they were terrified they might hurt patients, or even kill them, the report attested.

Media reports this past summer indicated that the Cerner platform was up and running at all four initial DoD pilot sites, with federal officials saying the agency is still troubleshooting the platform at the initial facilities, but the overall adoption’s shown “measurable success.” This month, media reports indicated that DoD is moving onto a second set of site locations for its Cerner EHR rollouts, with three bases in California and one in Idaho.

According to the VA press release issued last week, collaborating with DoD will ensure that VA “understands the challenges encountered as DoD deploys its EHR system called MHS GENESIS; adapts an approach by applying lessons learned to anticipate and mitigate known issues; assesses prospective efficiencies to help deploy faster; and delivers an EHR that is fully interoperable.”

While both Levin and McNamee praise the VA-DoD interoperability efforts, they note the substantial challenges the effort faces. In a January blog post, Levin wrote at the heart of this VA-DoD interoperability challenge are two fundamental issues: “an anemic definition of interoperability and the inevitable short comings of a ‘one platform’ strategy.”

In response to the joint statement issued last week, Levin provided his observations via email: “DoD and VA will have separate instances of the Cerner EMR. They will not be on the same EMR with a single, shared record but rather on distinct and separate implementations of the same brand of EMR. The choice of language in the announcement is interesting: they are saying they will create a single EHR [author’s emphasis] through interoperability between these separate EMRs and with the EMRs in the civilian health system, which is essential since a lot care for active duty, Veterans, and dependents is rendered outside the military system. This will depend greatly on the extent and depth of interoperability between the different EMRs.”

Levin continued, “My second observation relates to interoperability between the EMRs, or EHR system, and the many other apps and data services within military health IT. For example, there is an emerging class of apps sometimes referred to as ‘wounded warrior’ apps. These are specially designed for this population. They will need to be effectively integrated into this new IT ecosystem or their value will be greatly diminished, if not lost.”

McNamee points out there are different layers of interoperability—data interoperability, or ensuring data flows back and forth (the Joint Legacy Viewer achieved this level of interoperability, he says), semantic interoperability, in which meaningful information is associated with the data, and then standards-based process interoperability.

The lack of standards-based process interoperability continues to be a roadblock for all healthcare providers, and this issue has yet to be solved by any one specific EHR vendor, many industry thought leaders note.

“The challenges that VA and DoD face are similar to what the rest of healthcare faces in this country,” McNamee says. “There’s more than 10 million patients between these two organizations, meditated across thousands of different sites and the inability to transfer information and process for the VA and the DoD is similar as the rest of the country.”

He continues, “If you talk to any informatics or health IT professional about the most challenging thing that they’ve ever had to do in their career it’s to install an EHR into their hospital; it’s incredibly disruptive and, if not done well, it can negatively impact patient care, reimbursement and morale. VA and DoD are attempting to do this across thousands of healthcare sites, with millions of patients, and hundreds of thousands of healthcare providers, in one project, that’s a daunting task, to do that well and do that seamlessly.”


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Carequality Seeks Input on FHIR-Based Exchange

October 12, 2018
by Rajiv Leventhal, Managing Editor
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Carequality is seeking input from the healthcare community as it looks to add support for FHIR (Fast Healthcare Interoperability Resource)-based exchange.

According to an announcement from Carequality—national-level, consensus-built, common interoperability framework to enable exchange between and among health data sharing networks—member and non-member stakeholders from across the healthcare continuum are encouraged to participate in the new FHIR Implementation Guide technical and/or policy workgroups. The former will concentrate more on specifications and security, while the latter will focus on the “rules of the road,” officials said.

With much of the healthcare industry either starting to implement FHIR at some level, or planning to do so, the Carequality community is thinking ahead to the type of broad, nationwide deployments that Carequality governance can enable, officials noted.

The new policy and technical workgroups are expected to work in concert with many other organizations contributing to the maturity and development of FHIR, and officials attest that the workgroups will not duplicate the work that is underway on multiple fronts, including defining FHIR resource specs and associated use case workflows. Instead, the workgroups will focus on the operational and policy elements needed to support the use of these resources across an organized ecosystem. 

“Carequality has demonstrated the power of a nationwide governance framework in connecting health IT networks and services for clinical document exchange,” said Dave Cassel, executive director of Carequality.  “We believe that the FHIR exchange community will ultimately encounter some similar challenges to those that Carequality has helped to address with document exchange, and likely some new ones as well.  We’re eager to engage with stakeholders to map out the details of FHIR-based exchange under Carequality’s governance model.”

Cassel added, “We believe that adoption of FHIR in the Carequality Interoperability Framework can advance all of these goals by improving the availability of useable clinical information, expanding the scope of exchange, and significantly lowering the costs of participating in interoperable exchange.”

In August, Carequality and CommonWell, an association providing a vendor-neutral platform and interoperability services for its members, announced they had started a limited roll-out of live bidirectional data sharing with an initial set of CommonWell members and providers and other Carequality Interoperability Framework adopters.

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