Working with FHIR: Micky Tripathi’s Vision of Standards-Driven API Development in Healthcare

April 27, 2016
Micky Tripathi, CEO of the Massachusetts eHealth Collaborative, shared with me a nuanced, insightful view of the journey ahead on interoperability in healthcare—one that avoids the binary thinking so common in healthcare

It is always stimulating, bracing, and refreshing to speak with Micky Tripathi, especially in person. Tripathi, who participated in a panel on interoperability at the Health IT Summit in Cleveland last week (sponsored by our sister organization, the Institute for Health Technology Transformation, or iHT2), had  lot to say—all of it deserving of thorough reflection—at a panel entitled “Interoperability & HIE: Strategies for an Evolving Health System.”

Everyone who participated on that panel—moderator Mark W. Stevens, principal at ARRAHealth Consulting, and fellow panelists John Santangelo of Cleveland Clinic Florida; Kerry McDermott of the Center for Medical Interoperability; and Jitin Asnaani of the CommonWell Health Alliance—shared terrific comments and insights regarding the rocky journey towards interoperability in U.S. healthcare. But I felt a special excitement in listening to Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative. Tripathi has always been particularly knowledgeable and candid in his presentations and commentaries at the healthcare and healthcare IT conferences I have attended and participated in.

And he didn’t disappoint this time. Asked what he thought about the FHIR (Fast Healthcare Interoperability Resources) standard and its potential to help IT leaders get to true interoperability in healthcare, Tripathi said that “There are reasons to believe FHIR could help us. My caution: it is still a very nascent, primitive standard; it’s just a technical standard,” he added. “There are business, legal, and cultural issues. I don’t think we should kid ourselves and believe that a new standard will fix everything. But FHIR does democratize to help us move to the next level,” he continued. “It is based on the same types of interoperability processes in other industries. Other industries see healthcare as a backwater that they would never want to get involved in, because we use moribund standards from about 1985. FHIR is based on principles and basic Internet patterns that Facebook, Google, Amazon, Uber, are using. So there’s a democratizing aspect of it, so developers will start to come into the space as we move forward with it.”

Tripathi went on to say of FHIR, “Also, it’s a true data-level standard. Right now, we’re exchanging continuity of care documents, which is important, but you’re not able to get to the next level, app engagement, until you have true data-level standards, and FHIR does that. So at Argonaut, we’re saying, let’s have this as a workable standard and build on that. There’s a lot of FHIR hype, which is both good and bad.”

And then, once the panel discussion had concluded, Micky sat down to speak with me and to share additional thoughts on where the industry is with FHIR right now. That interview can be read here.

The thing that struck me in discussing FHIR with Micky is how brilliantly balanced and nuanced his views of all of this are. So often in healthcare, around any subject, whether it’s policy, payment, operations, clinical practice, or information technology, people end up taking strong sides, and often assuming black-and-white views of really complex topics. And interoperability is really, really complex, both in itself and also as a topic of discussion. And a lot of the talk around FHIR has been a bit overheated, shall we say?—with partisans of “yes” and “no” both sometimes overstating their cases, one could say.

So it was refreshing and stimulating to listen to Micky share his extremely well-informed perspectives on what FHIR can and cannot do for healthcare IT and especially API, development. For example, he told me, the widespread adoption of FHIR “will be an opportunity for developers to come in. It will be the crowdsourcing phenomenon. They’ll bring fresh eyes and new use cases. And then that will enable me to exert real demand on vendors.”

On the other hand, Micky told me of his concern over what he sees as the current overhyping of FHIR. He noted that the Orem, Utah-based KLAS Research “did an interoperability study in the late fall. And one of the things they asked providers was, what do you think will be the biggest opportunity and hope for interoperability in the future? And FHIR was number one. And I’m going to bet you that 90 percent of those people don’t really know what FHIR is. In working with FHIR, I still have to figure out the trust issues—legitimate security and privacy issues—how do I know that you’re authorized, from a HIPAA [Health Insurance Portability and Accountability Act] perspective, to interact with my data? A standard doesn’t solve those issues. Those are business and legal issues.” He shared with me other concerns as well, noting that “[T]here is still a question of, who’s going to be responsible for those APIs? There are already reports on security issues around them. Who’s going to be responsible for the fact that an API is making ten behind-the-scenes calls when you sign up or sign in? And there are no regulations around any of that.”

In other words, the adoption of FHIR is going to bring many opportunities to healthcare IT, in terms of development in general, and especially in terms of interoperable APIs. And that is all terrific. But as Micky noted, FHIR is a standard, not a panacea for all the application-development issues currently hobbling the industry, on the road to interoperability.

So things are very complex, and will remain so. And yet in the end, Micky Tripathi, one of the most thoughtful and insightful of industry experts, when I asked him how optimistic he was regarding the trajectory towards interoperability, told me this: “I’m really optimistic, because I think we’re now at the point where you have this kind of network maturity where you can figure out ways to mimic what’s happening in other industries. Now, these networks are starting to form. It’s thanks to network maturity.”

It seems to me that Micky has all this exactly right: the way forward towards interoperability in healthcare—just like the way forward towards optimizing reimbursement to improve care quality and population health management—will always be complex, challenging, and long. But as Micky pointed out to me, there is cause for both optimism and caution. So let’s all forswear binary thinking in this, as Micky already has—because this will inevitably be a long journey forward, and we need all the nuanced, insightful thinking we can get.

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