What can the government do to better enable health information exchange (HIE)?
That’s the core question the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator (ONC) for Health Information Technology recently asked in a request for information (RFI). Last year, the ONC declared that the answer to that question wasn’tcentral governance in regards to a Nationwide Health Information Exchange (NwHIN), and now it is looking for other ways to help.
At a recent Health IT Policy Committee meeting in Washington D.C., Micky Tripathi, founding president and CEO of the Massachusetts eHealth Collaborative (MAeHC) and chairman of the Committee’s Information Exchange Workgroup, extensively weighed in on that question. In an exclusive interview with HCI’s Associate Editor Gabriel Perna, he discusses his thoughts on what government’s role should be in this area and the various obstacles that make it difficult to achieve.
One thing Tripathi supports is an organization like the Direct Trust, a non-profit that has created a framework that allows for the safe exchange of health information. He doesn’t necessarily advocate for Direct Trust itself, but rather for a federally sanctioned organization that operates in the same kind of vein would get people to play by a similar set of rules.
Tripathi also advocates for giving providers and patients a Direct type of address through Medicare/Medicaid enrollment. In addition, he says ONC should make certain types of data available that other people could use to better enable HIE.
“For example, the ability to create a nationally available provider directory would be something that is greatly enabling for health information exchange,” Tripathi says. “Right now the federal government sits on huge data repositories of physician information, because all of those physicians are either attesting to meaningful use or they are Medicare/Medicaid network participants, so they have to go through an enrollment process. They could take some of that data, and in a way that doesn’t breach the privacy of physicians, and provide a provider directory that the private market could grab that and create a richer directory as a feed.”
Matter of Trust
According to Tripathi, interoperability will be driven through demand. He sees this occurring more frequently as the pay-for-performance payment model gets pushed to payers and providers. Regulatory programs like CMS’ Value-Based Purchasing (VBP) and Accountable Care Organization (ACO) Shared Savings Programs, he says, “put them [providers] in a position where they need to be interoperable, because they need information on where the patient is going, if they have any hope of managing the risks of trying to prevent high-cost events that don’t contribute to the quality of care.”
But as Tripathi notes, the built-in elements of fragmentation of the healthcare system continue to pose obstacles to nationwide interoperability. “Up until now there hasn’t been a huge market incentive, a business driver, to push hard for the exchange of information [on a national scale],” he says.
Fragmentation of this nature can take shape in multiple ways, such as the variances between state HIEs, which has made nationwide interoperability a challenge. He says, one of the challenges in this regard is that there are 56 states and territories, and the federal system gives a lot of policy authority of health information exchange to state-based organizations.
For example, Tripathi says that many states have privacy laws that supersede the requirements of the Health Insurance Portability and Accountability Act (HIPAA). “As you think about cross-state exchanges, it becomes a real question – what am I allowed to do if a patient lives in one state and gets their care in another state. Which laws apply? Does the patient understand that, let alone the organization? It’s starts to become very complicated on how to stay true to all the laws that are going to be touched upon when the bits and bytes go across state lines,” he says.
According to Tripathi, the whole issue is a matter of trust, and not in the sense of “I don’t trust you, but rather I don’t think you understand my laws, and I don’t understand yours, and for the life of us, we don’t know how to align them.” The other area of trust, he says, is in regard to access to information and networks. He says there is a question of authentication and authorization. Essentially, are you sending information to a legitimate care provider and if so, are they authorized to see this information?
“That becomes more difficult as you think about these cross-network exchanges. It’s not just trust from state to state, it’s vendor to vendor, or state to vendor,” Tripathi says. If a state health information service provider (HISP) trusts a vendor’s network like a Cerner (Kansas City), and a hospital in Montana has Cerner, it could theoretically connect with any provider on that HISP.
The reason for the slow approach to nationwide HIE governance, as Tripathi says, is “you don’t want to go too deep, too fast.”