At iHT2 Boston, Micky Tripathi's Refreshing Take on Interoperability

June 28, 2016
During a closing keynote presentation last week at the iHT2 Boston Health IT Summit, Micky Tripathi, Ph.D., president and CEO of MAeHC, debunked certain healthcare interoperability “myths” while offering a positive outlook on the future of data exchange.

During a closing keynote presentation last week at the iHT2 Boston Health IT Summit, Micky Tripathi, Ph.D., president and CEO of the Massachusetts eHealth Collaborative (MAeHC), debunked certain healthcare interoperability “myths” while offering a positive outlook on the future of data exchange.

The event, from the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under the Vendome Group, LLC corporate umbrella), took place at the Aloft Seaport Hotel in Boston on June 23-24, and closed with Tripathi’s Friday keynote on healthcare interoperability.

In addition to his role at MAeHC, a collaboration of Massachusetts provider, payer, and purchaser organizations, Tripathi wears various of other health IT hats: he is chair of the Information Exchange Working Group and co-chair of the Privacy and Security Tiger Team (both of the federal Health Information Technology Policy Committee), a director of the New England Health Exchange Network (NEHEN), and a director and past board chair of the eHealth Initiative. Simply put, when it comes to interoperability and standards, no one in health IT is better well-versed than Tripathi. I compare it to the NBA, when players who consistently can score the basketball are labeled “go-to guys.” For healthcare, Tripathi is the go-to guy for all things interoperability.

Tripathi opened his presentation by asking two questions to the room full of attendees: first, if they believe information blocking significantly exists in healthcare; and second, if they think that the healthcare sector is woefully lagging behind other industries in terms of being interoperable. Predictably, the majority of hands raised in affirmation to both questions. Knowing this would be the likely answer to his two questions, Tripathi moved on in an attempt to debunk these “myths.”

Indeed, looking at other industries, Tripathi noted how he gets Google Calendar invites all the time that don’t sync well in Microsoft Outlook. Or, he said, books purchased at Barnes and Noble don’t play on the Amazon Kindle. He gave several more examples of how in other businesses, companies don’t always “play nice” with one another: Apple isn’t interoperable with anyone; Netflix and Verizon recently had a fight about who should pay for the infrastructure for Netflix consumers, resulting in poor streaming quality; Fitbit has said that it’s not connecting with Google Fit, choosing to create its own network; and finally, consumers can no longer use another coffee cup in a Keurig anymore.

“Interoperability problems are rampant across all industries, public safety included,” Tripathi attested. “I'd argue that [these examples] are no different than what's happening in healthcare. In some ways, since we have higher expectations in healthcare, we are actually doing better. We need to exchange data; other industries might not have to.” Tripathi then touched on how these interoperability issues get “resolved” in other industries, offering the example of universal product codes (UPC) in grocery stores that adopted them after having problems with inventory control. “Grocery stories created UPCs with a bunch of other grocery stores and vendors. They wanted to all purchase the same machines and get value from them,” Tripathi explained.

Thus, as HIE [health information exchange] matures, it is starting to organize itself like other industries, Tripathi said. Now the question becomes, how are these data exchange networks going to form? The early notions were of a single, federal top-down network, and that collapsed as an idea. But now, networks are starting to form, he said. “It’s not about connecting an EHR [electronic health record] to an EHR, but about being a part of a network and connecting a network to a network. That's how the rest of the economy has solved the issue in literally every instance.”

Tripathi pointed to several examples of separate networks forming and connecting in healthcare today. He brought up the eHealth exchange for government data, the Mass HIway for local, state-based, lightweight exchange in Massachusetts, Surescripts, for e-prescribing, DirectTrust for secure email, and Carequality as an emerging framework that allows query-based exchange among different participants. “We have so many different ways to communicate with one another based on the kind of communication we want, so we have different networks—just like any other industry. The original notion was to have one way of health information exchange, but there are very few examples where that has worked,” Tripathi said.

He continued, “What type transaction do you want to make? DirectTrust is nationwide interoperability of secure email, and it doesn’t do anything else. But it's something that has been carved out from the broader picture.” This is different than the all-or-nothing approach, or “HIE 1.0,” in which data would be dumped into a repository for everyone to be able to use for multiple purposes, Tripathi said.

Tripathi then noted how the marketplace is just beginning to see solutions for point-to-point query exchange, so a provider can query someone else’s system to get a record document, and then query another system. Carequality and CommonWell are starting to solve this problem, Tripathi said, adding that pretty much every major vendor except Epic, NextGen and GE are on board. And regarding Epic’s exclusion in these interoperability frameworks, Tripathi reminded folks that while there is not yet interoperability between CommonWell and Epic (Epic’s Care Everywhere product is for Epic users only), looking at other industries as a precedent proves that it will eventually happen in healthcare, too. “These are the beginnings of a nationwide network to solve the point and retrieve issue,” he said.

FHIR is Just a Standard

While Tripathi repeatedly pushed the idea that healthcare is not as in much trouble as people like to say in terms of it users’ ability to exchange data, he did caution that the FHIR (Fast Healthcare Interoperability Resources) standard, while certainly a big part of health IT’s future, is not the magic bullet to solve all interoperability problems. “Have we hit the peak of the hype curve?” Tripathi asked. “FHIR is being talked about as the universal magic bullet. I am amazed by the hype of it. People are looking for an answer, and need a magic bullet,” he said.

But more than that, FHIR is a genuine data-level interface that allows a provider to ask another provider just for allergies for patient X, for example, Tripathi added. Right now, he noted, a provider might receive an entire C-CDA (consolidated-clinical document architecture) document even though he or she just needed the allergies. “With FHIR, you can say ‘here are the allergies.’ So that's why there's excitement around it. It gets us closer to the data integration goal that we all want.”

Nonetheless, Tripathi referenced a KLAS interoperability survey from last fall which found that FHIR was the top thing people were excited about. “But I'd bet that 90 percent of those people can't tell you much about FHIR at all,” he estimated. “I'm a big proponent of FHIR, but people will realize that it's just another standard, and it won't solve problems like money, legacy systems, and things like that.”

Tripathi is the project manager of the Argonaut Project—an initiative launched by Health Level Seven International (HL7) to accelerate the development and adoption of FHIR— where leaders there are currently writing app-enabled implementation guides in which a person would be able to take a mobile app or host of applications and be able to have those apps connect in a seamless way. That's the hope of FHIR, and it’s based on RESTful application program interfaces (APIs), which the rest of the Internet is based on, Tripathi noted. “Once you base it on something like that, you bring in a lot of other brains that are willing to experiment. There is a whole economy of developers out there right now that don't want to enter healthcare world because they think standards we use are 25 years old. And they're right.”

One of FHIR’s challenges, Tripathi continued, is that a whole ecosystem has to form. “People get excited about the notion of having apps and just connecting them. Providers want the apps, and EHR vendors also like the idea of apps because they can't keep up with the demand,” he said. “Medicine is way too complex, so a Cerner or an Epic can't implement those things. So they like idea of plugging your app into their system. But an ecosystem needs to form around that. How does that work?” He mentioned the Apple store or the Google Play store which act as intermediaries where a user can go find those apps, following basic usability and quality principles, and some security principles. But Tripathi wanted to know where this happens in healthcare and who will ultimately step up to the plate.  

He added that there are several options of how this can occur in healthcare, and who the app store pioneer will be is still up for debate.  Possibilities, according to Tripathi, include: Geisinger or a similar health system; major EHR vendors; a third-party company; or the SMART (Substitutable Medical Applications & Reusable Technologies) on FHIR app gallery, which as of today, is the closest we have come to a vendor-neutral app environment. That could be the place that becomes trusted first, Tripathi acknowledged. However, the one organization that the industry cannot afford to do it is the federal government, he said. “There was talk about it, but we absolutely don't want that. That can go down a bad path, and really quickly.” Tripathi himself is betting on EHR vendors and provider organizations who will lead the way.

Certainly, listening to Tripathi’s keynote was particularly fascinating for me, since I’m mostly told how it will be years before we see true interoperability in healthcare, an opinion that was hammered home at a recent iHT2 event in April. To this end, I wrote a blog earlier this month about how 2015 data exchange numbers amongst U.S. hospitals—particularly the ability of providers to perform all of the core functions of interoperability—were nothing to write home about.

It’s certainly possible that it will take five to 10 years, or perhaps even more, for healthcare interoperability to catch up to other industries. But I don’t think that was Tripathi’s point with his keynote last week in Boston. Rather, he wanted to call out the improvements that we have seen over the years, and prove that healthcare is far from the only sector with system connectivity problems. It was extremely refreshing to hear Tripathi’s expert and balanced take on the topic. Once again, healthcare’s interoperability “go-to guy” delivers.

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