Micky Tripathi on interoperability
As co-chair of the joint HIT Policy and Standards Committee's JASON Task Force, Micky Tripathi is charged with digesting the report, "A Robust Health Data Infrastructure," prepared for AHRQ by the MITRE Corporation's JASON advisory group, and making suggestions to ONC about what to do with its findings on healthcare interoperability.
We spoke with Tripathi, the CEO of the Massachusetts eHealth Collaborative, about the JASON report, about the systemic challenges standing in the way of more fluid data exchange, and about the future of interoperability in the U.S.
Q: What is the mandate of the JASON task force?
A: The original question that was asked of them by the federal government was really to look at the ability for health information exchange to contribute to a platform or platforms to be able to do better research, to improve healthcare. It was very focused, the original question was focused on that: If it can help with clinical care, great, but it was really focused on this question of how can it help to enable research.
But then, I think, if you read the report, you see one of the things they look at and are struck by, which I think most people would agree with, is that, jeez, interoperability really isn't very far along. It's really not where any of us really hoped it would be. I think that that's an observation that resonates with people: Its unsatisfactory, in many ways, where we are right now.
So they came up with a proposed architecture and proposed approach for thinking about how one might enable a way for a nationwide approach, to have an ability to aggregate and normalize information, such that it can be used for clinical care, used for research, and used in a better way by patients to manage their own care.
So that's roughly what the JASON report was about and the solution they proposed. We've got the task force now that is looking at it, and we're still in the middle of our deliberation, but I think one of the things we've talked about on the public workgroup calls is a sense that the overall perspective of the JASON authors is, 'Yeah, we're not as far along as we'd like to be.’ There's is a sense, though that there's probably more progress in various types of health information exchange than the JASON authors seem to give credit for.
Some of that may have to do with timing. They were asked to start on this almost two years ago. There's a long lag in the process – they put together the committee and embark on their investigation and they issue their report and the government approves the report, then decide to release it. They started thinking about this two years ago, and only now are we seeing the report. So it may be that they didn't have the opportunity, because a lot has happened over the past two years.
Q: Still, it’s difficult to argue we are where we should be. Why is interoperability so hard?
A: Up until now there hasn't been enough demand for interoperability in healthcare. A lot of people have the perspective that there has been a negative motivation behind that: people wanting to hoard their data and not share it with others. I'm sure there's some of that. But I think there's a genuine lack of demand for a variety of other reasons.
Some of them are cultural. Physicians aren't trained to think, 'I need to get data from other places in order to take better care of my patients." Both my parents are physicians and they'll always say that they were never trained that way – almost with the opposite: You got what you got, and you'd better make some good decisions based on what you got. Not, “I'd better pause and wait to get more information once it's critical.” There's a financial aspect to it as well, which is just the fee-for-service model.
The other thing I would add is the fragmentation of the industry. If you think about how other industries – almost every other industry in the U.S. – if you look at what percent of the industry accounts for X percent of all the activity that happens in that industry, and it gives you a measure of its concentration. And it turns out that healthcare, both the demand side – meaning patients and purchasers, like health plans and employers – is very fragmented. And then the supply side – providers, first and foremost, and hospitals – is extremely fragmented as well.
That's a market impediment. But I think that dynamic has changed.
Q: Why, and how so?
A: Meaningful use was obviously a big driver in changing that. To me, the one market player that's the counterexample to everything I was just saying is Medicare and Medicaid. Leave aside that they happen to be owned by the government – they're big health insurers, and they're the only ones who are big enough to move the market. That's true for ICD-10, it's true for CPT codes, it's true for every other thing in healthcare. Medicare and Medicaid tend to be huge drivers because they're so big in the market, not because they're the government, necessarily.
And so when they started to embark on MU, and said, when you start doing this stuff, we'll give you an incentive to do it, they like Walmart are so big in the industry that all of a sudden it started to move the industry in a new direction. That was the incentive to change the way people start thinking about this. Everyone starts to have EHRs, which is essential to interoperability: You can't talk on telephones if everyone doesn't have a telephone.
Accountable care is starting to create this culture where, if you do that extra MRI, the ACO is going to be on your back saying, 'Wait a minute, that was actually available in one of our partner hospitals, and you should have known that before ordering that expensive test.
It's not widely penetrated across the entire market, but I think in certain markets it's starting to change the way providers think about those purchase decisions. And that leads to demand for health information exchange. We're starting to see more and more organizations saying, 'I can't possibly meet this risk contract. I'm bearing the risk of costs being greater than a certain amount, if I don't have the ability to first off have information, which requires interoperability, and second the ability to act on it.'
Q: Maybe we should take some satisfaction of where we are today, then.
A: I think the HIE story is a really good story now. Not because we've accomplished more. If I look back on my 2004 self, I would have thought that in 10 years we'd be further along than we are now. On the other hand, I guess I feel really good about it because I think a lot of what happened, especially with the HITECH dollars.
If you give people money – we had $50 million for our pilot projects, CMS giving $25 to $30 billion – we can throw money at it, buy technology for people, put it in their offices, and then find that they still don't do it because there are so many barriers to it: cultural, legal, policy barriers – and workflow barriers.
If you look at how innovation happens in any industry, it often starts with product innovation, where people have fancy, cool new toys that get put out in the market. But there's been a lag: a bump up in product innovation – and then there's this real lull because process innovation has to take over to really incorporate those new products. We're seeing that in healthcare.