Micky Tripathi, Ph.D., founding president and CEO of the Boston-based Massachusetts eHealth Collaborative (MAeHC), isn’t afraid to buck the tide of received wisdom and current opinion, and his perspectives on the future of health information exchange (HIE), which he shared with HCI Editor-in-Chief Mark Hagland on Feb. 25, at HIMSS14, the annual conference of the Healthcare Information and Management Systems Society, being held this week at the Orange County Convention Center in Orlando, Fla., are in no way reticent. Tripathi’s vision of the future is informed by years of experience at the helm of one of the most successful collaboratives of its kind in the U.S., and he shared his insights on the swirl of ongoing developments around HIE without hesitation. Below are excerpts from that interview.
What is your opinion of the letter to Secretary Kathleen Sebelius, signed by CHIME and 47 other healthcare associations?
[On Feb. 24, leaders at the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME) and 47 other healthcare associations co-signed a letter to Health and Human Services Secretary Kathleen Sebelius, calling for “additional time and flexibility in the meaningful use program to ensure its continued success.”] I think that effort really reflects that there are too many things hitting the industry at once. I think it’s a good thing to give people the flexibility they need. The reality is that none of us could have predicted that you’d have meaningful use Stage 2, ICD-10, OCR [HIPAA data security audits under the auspices of the Office of Civil Rights at the Department of Health and Human Services], the ACA [Affordable Care Act], all at once. And it’s pretty miserable being a hospital CIO right now—it’s not a fun job! You have a lot of risk and a lot of exposure, and a whole range of issues, like BYOD.
Is this an unprecedented time for CIOs and other healthcare IT leaders?
Absolutely; it’s completely unprecedented. And their importance is rising, in terms of how important IT is. Everyone’s expecting innovation going forward, in terms of new reimbursement and care management models, and yet CIOs are saying, I can only handle compliance right now. And ICD-10 being pushed out for a year is now a huge issue. We’re helping to lead collaborative ICD-10 testing in Massachusetts, and it’s turning out to be extremely time-consuming.
People are saying these days that, fundamentally, health information exchange is just too difficult. What is your reaction to that sentiment?
If one wants it to be rational and a hierarchical learning structure, in which everyone learns in a direct way—yes, in that sense, it’s too hard. But where else has that ever happened in the U.S.? We’re an incredibly large, heterogeneous country. To me, HIE is flourishing; but it’s flourishing in different ways than we expected—in a sort of bottom-up way. One way in which it’s flourishing is in terms of demand in relation to supply. It’s very hard to go to a hospital that isn’t thinking about this very hard or isn’t already embarked on something. Everyone’s thinking about it.
And on the supply side, there are lots of technologies, very tactical technologies, that people are leveraging, to create HIEs. And people aren’t expecting to simply plug in an established model. And most of the HIE 1.0 HIEs failed—and the ones that survived—Indiana, Cincinnati, and New York—those that survived from that 1.0 generation, those are not replicable.
So the newer ones are moving forward in replicable ways?
I think so, yes, but each is unique. And Baystate Medical Center has formed a private HIE, and in a year, it’s already up and running, and there’s good anticipation. But it’s very, very focused, very tactical; and they’re not trying to solve the world’s problems; and it’s their own private money. Emerson Hospital, and Anna Jacques Hospital, they’re all doing the same thing, in different ways, attuned to their specific needs.
So uniqueness of approach is OK in HIE development, then?
Absolutely. In the same way that uniqueness is OK in any kind of fragmented industry. And in terms of auto companies and retailers and airlines—consolidation eventually happened. It’s unclear where that driving force will come into healthcare, because you start out with incredible fragmentation on both the demand and supply sides.
It almost has to be Medicare driving development, in other words?
Yes, and up until now, it’s been incredibly fragmented on both sides; but Medicare and Medicaid are just the biggest entities, and so they’re able to move the market. But the nature of physician practice and the ambulatory setting is going to mean the supply side will remain fragmented.
Now that physicians are consolidating into hospital organizations and large medical groups, will that change the landscape of HIE development?
Yes, I think so. HIE is flourishing, but in silos. I think it was a bad expectation to assume that once HIEs were created, all the barriers would immediately fall. Well, that didn’t take into account business realities. So we’re seeing a lot of investment in silos like integrated health systems and ACOs—and I don’t see that as a bad thing. Accountable care organizations are making investments based on sharing risk.
There was this kind of idealized notion of what HIE would do, then?
Absolutely. And who is the demander for information exchange, and what does that mean? There’s an interest in public health and population health, but all of that is woefully underfunded. So when you start to say, I want to be able to solve the use case of, Mrs. Smith goes to Colorado breaks her ankle, and we want to make sure that that small, rural hospital will have the patient record back in Massachusetts, well, there’s no use case that can be supported for that.
So where is HIE headed in the next couple of years?
Well, I think it’s hard to predict, as it is in any fragmented industry. It’s easy to make confident assumptions about what will happen in retailing, for example, around big players like Target or Wal-Mart. But in other areas, it’s much more difficult.HIE is that way. We don’t know what the business models will be, what the technologies will be, who the players will be. But we can say, number one, that it’s going to continue to flourish; I don’t see anything standing in the way of that. It’s going to be very, very tactical, and different from place to place. And it will be more demand-driven—I think that there is a standard of care assumption about interoperability as a standard of care that is beginning to take hold—and whether that’s coming from providers, in terms of feeling the need to provide for that—as well as hospital readmissions work.
Looking at the industry landscape at this HIMSS Conference time, what are your impressions overall?
It’s all exciting; and to me, we just have to have deep respect and humility about the market; this is a market, at the end of the day. And so many people want everything to be figured out for them, but that’s not the way that the healthcare market works in the United States. And arguably, we have to accomplish things the hard way. And that’s arguably true for everyone else, too—look at the UK. The only examples where total top-down has really worked is Singapore, where there’s no chewing of gum. And that’s just not our culture.
Where should our readers’ minds be right now around HIE development very broadly right now?
I think that it’s really important to focus on the very specific things that are important to your business needs, and doing it in a way that you can actually derive concrete value. On NPR the other day, they did a segment on the state health insurance exchanges. And then they had someone who said, the ones doing the most are the ones doing the least; and that’s true of health information exchanges, too. The successful ones are focused on very specific things they could accomplish. They’re not trying to boil the ocean. It’s about figuring out how do you do the least that delivers value. So for a CIO, figuring out what the real interoperability needs are. And one of the things we do for CIOs is to figure out how to draw that line between B2B versus supplier side integration. And we sit down with CIOs and actually create a list of all their interactions with other clinical organizations; and inevitably, we end up with a list of something like 35 or 40 organizations. And then we ask them, what organizations on that list affect your quality of care and business performance, and vice versa? And inevitably, that’s more like five or six organizations. And CIOs understand that; but inevitably, they can end up trying to do too much.