The Past, Present and Future of Interoperability

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Bill Russell / Micky Tripathi

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November 6, 2020:  Interoperability. Where have we been, where are we now and where are we going? Micky Tripathi, Chief Alliance Officer at Arcadia helps us untangle the intricate web of data and analytics in healthcare. There’s a minefield of acronyms TEFCA, RCE, USCDI, QTF, FHIR, QHIN. How do we piece them together in this environment of policies and regulations? Is the 21st Century Cures Act the starting point for changing how we currently do things on a national level? What about a local level? Do we anticipate opening up digital health data to the world of developers in collaboration with health providers and even payers? Will we see a whole new set of applications?

Key Points:

  • The creation of a nationwide framework to bring networks together under a single governance [00:11:00] 
  • TEFCA is a nice overlay but it isn’t necessary to accelerate the market [00:12:55] 
  • An important part of the 21st Century Cures Act is information blocking [00:13:00] 
  • Da Vinci HL7 FHIR [00:27:40] 
  • Apple is not technically under HIPAA. What does this mean and how can it be addressed? [00:33:45] 
  • https://www.arcadia.io
  • Micky Tripathi Twitter
  • Email: [email protected]

The Past, Present and Future of Interoperability with Micky Tripathi

Episode 325: Transcript – November 6, 2020

This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.

[00:00:00] Bill Russell: [00:00:00] Today on This Week in Health IT we have a great conversation with Micky Tripathi. We’re going to cover the past, the present and the future of interoperability and Micky is fantastic cause he’s been there from the beginning. And he is leading us into the future. So I really appreciate his insights and look forward to sharing that with you.

[00:00:22] My name is Bill Russell, former healthcare CIO, CIO coach consultant, and creator of This Week in Health IT a set of podcasts, videos, and [00:00:30] collaboration events dedicated to developing the next generation of health leaders. I want to thank Sirius healthcare for supporting the mission of our show to develop the next generation of health leaders. Their weekly support has given us the ability to expand our services and develop new offerings for the community. Special thanks to Sirius sponsorship. Let’s see. Oh, couple, a couple just quick bullet points we have. You guys are taking advantage of the clip note referral program and, keep doing that. Send your friends over to the website this [00:01:00] weekhealth.com. And I have them sign up, put your name in as the referred by, and you will get signed up for potentially winning a work from home kit from this week in health IT. 10 referrals gets you this, this week in health, it moleskin notebook and a 1. whoever gets the most referrals will have the opportunity to sit with me on the Tuesday News Day show. And that will be fantastic. We’ll have a good time. You’ll get to take Drex to DeFord’s spot for a week, and we will have a conversation about the news. [00:01:30] So keep those coming. Micky and I talked for about 50 minutes here.

[00:01:34] This is a little longer than usual. I just want you to know it’s worth every minute of your time. So I’m going to get right to the show. Here we go.

[00:01:41] Today I’m excited. We’re going to talk about the history of future and promise of interoperability with Micky Tripathi, who has really been there from what feels like almost the beginning. Welcome to the show, Micky. 

[00:01:55] Micky Tripathi: [00:01:55] Thanks. Really delighted to be here. 

[00:01:57]Bill Russell: [00:01:57] I’m reading your bio and I [00:02:00] just read it to the group. It has every, group and acronym related to interoperability. So we’ll establish your credibility pretty quickly here. So you were Micky Tripathi was pioneer in healthcare, interoperability, active in the industry at the local and national level, including memberships of the board of directors of HL seven scoria project, CommonWell Health Alliance, the carrot Alliance and the HL seven fire foundation and the project manager of the Argonaut project and industry collaboration of the to accelerate the adoption of [00:02:30] FHIR. He is a former CEO of the I’m going to say this wrong, Massachusetts EHC, 

[00:02:36] Micky Tripathi: [00:02:36] which is healt collaborative, 

[00:02:39] Bill Russell: [00:02:39] and recently joined Arcadia as chief Alliance officer that covers everything right there. Karen Alliance, CommonWell, HL, seven fire. you’ve been a part of this for a long time.

[00:02:51] Micky Tripathi: [00:02:51] I have I try to help where I can and try not to be spread too thin, which is a talent. 

[00:02:57] Bill Russell: [00:02:57] Yeah. You probably get a lot of phone calls. I would think. [00:03:00] What I’d like to do is I’d like to talk about interoperability really past and future since you’ve been a part of it. Then I’d like to really transition into the promise of why are we doing all this? What’s the promise of data and analytics in healthcare? I know for me and my listeners, the furthest four, I came into healthcare in 2011, and the, interoperability was hard. I coming from other industries. So my first job in healthcare was in 2011 as a CIO. And we had data, quality issues, ontology problems we had, even sitting across from other [00:03:30] CIO saying, Hey, we want to share our data through an HIE with you and having a CIO, look at me and say, yeah, we don’t want to share our data with you. that was, to me, I was like, Man, this is a complicated deal that you don’t have to solve with technology. There’s a lot of different aspects to it. you know what, give us an idea of where you started with this and what prior progress you’ve seen, let’s just say over that timeframe from when you started.

[00:03:55] Micky Tripathi: [00:03:55] Sure. Yeah, no happy to. so yeah, I, I started, I [00:04:00] first got into, healthcare, it, really, just jumping right into, interoperability where, a lot of people enter, healthcare and health IT starting like in a provider organization where you’re working on all the various systems that are within the hospital, let’s say as you were describing, and then you start to think about how it builds up from there.

[00:04:20] And that’s where you start to confront the interoperability things. I came in a know, a different path, almost sideways. Where we were, I was working for a consulting firm at the time, the Boston consulting [00:04:30] group. And we were hired by a group of organizations in Indianapolis to come and help do some business modeling and business plan development for, what ended up becoming, I hired the Indiana health information exchange.

[00:04:44] So I spent a lot of time in Indianapolis working with, t legendary figures at the registry for Institute like clinic bottle, that Mark over Hage, working on developing a business plan for taking all the great stuff that the Reagan street Institute have been doing in [00:05:00] interoperability and figuring out a retail more commercial type of model to help extend that into the community. so I actually started interopibility and then started working backward into electronic health records but you know, but some of the, some of the issues that you had just described, in 2011, in 2002 all those issues were there and, and even worse and one of the biggest challenges I think was, that most provider organizations and certainly in the ambulatory side, didn’t have electronic health records. Right? It was really just the hospitals. So everything [00:05:30] that Indianapolis and the registry constituted accomplished had been connecting up the hospital systems across the city. And then, and you have the wide swath of care that’s out, you’d go to setting, which is, which, as we know, is where the vast majority of care happens was unconnected because no one had electronic health record systems. So that was, the first issue that we, that we confronted all of the other issues that, that you were talking about were, were definitely there, as well, the issues around standards.

[00:05:58] The issue is around [00:06:00] curation of data and normalizing data across those systems, that none of that’s been cured yet. and we can talk about fine, some of those problems still persist. and some of the competitive issues that you talked about as well, I think that’s getting better and better but over time, but certainly when we were watching III in Indianapolis, one of the things that we, spent a lot of time doing is, working with the hospitals to, to get, a consensus among them, that doing, interoperability, in the ways that we were talking about with the health information exchange, wasn’t really [00:06:30] competitive.

[00:06:30] It was more like, a joint venture. at the same way that they were pooling money to do joint laundry services. That was the analogy that I like to use. They used to say, you guys are all spending money, pooling your money to get more efficiency out of laundry for all your hospitals. You should be doing that for lab results delivery as well, because it doesn’t give you a competitive advantage to have your own. Provider portal, physicians actually hate that. They’d rather get everything through one place. 

[00:06:55] Bill Russell: [00:06:55] Yeah. And I’m going to really fast forward a lot and we’re going to start talking about 21st [00:07:00] century cures, tefka and some other things, but you make the jump to Massachusetts. Does the policy environment and the regulatory environment in Massachusetts make a difference in terms of what you were able to do in Massachusetts? 

[00:07:13] Micky Tripathi: [00:07:13] Yeah I think it was less the, it wasn’t necessarily the policy environment, but it was more the business charm, was a little bit different which allowed the, the creation of the Massachusetts health collaborative, and in, working with a number of other organizations who had already been, been in the state. So [00:07:30] one part of it was certainly that for whatever reason, in Massachusetts, there’ve been a lot of collaboration already that you have organizations like the Massachusetts health data consortium that was founded in the late 1990s. And they had launched a health information exchange called Meagan the new England health exchange network. And, and that was, up and running for a came right after the passage of HIPAA. Where, a group of very, leading CEOs like John Glasser, who was the CIO of partners and John Blanca, who was a CIO of Beth Israel and [00:08:00] a couple of others got together and said hey, we should before we all spend money on this new HIPAA, set of transactions that all of us know we have to do, why don’t we get together and do this together?

[00:08:10] So you had that. You know that climate where people had developed that trust from something that was successful, which I think is really important, but another really important, thing that, I think, is, makes every market different than Massachusetts is. You’ve got, this, I think of it as, game theory, which is you got the [00:08:30] providers and the military providers let’s say, and you’ve got the government and you’ve got healthcare payers and you have the payers. And in each market, there’s differences in the relative power of each of those groups. I think when you think about, and when you look at it market by market, it’s really different Massachusetts because it’s so concentrated among the payers. It’s really, three or four non-profit payers, who are Massachusetts based, who account for, 98% of the covered lives in the [00:09:00] state. And that’s a very different dynamic than like an Indianapolis where it was, something like 10 national commercial payers who accounted for 50% of the covered lives. And then the rest was like a long tail, right? So in Massachusetts you’re able to get, three or four payers together and agreed they’re going to do something.

[00:09:18] And all of a sudden you’ve got a lot of the market. it was already captured and that’s what happened with the mass scale collaborative, the blue cross blue shield of Massachusetts agreed to put some money forward to run a large scale health IT experiment that would be community-based [00:09:30] and that got, and it doesn’t take that, that much effort after that to get, a lot of the market together to be able to agree to move forward on something like this.

[00:09:38] Bill Russell: [00:09:38] Yeah. So it feels I’ve referred to this as the starting line and that might be a little offensive to someone like you who’s been doing this for 20, some odd years, but 21st century cures, really, maybe not the starting line, but it really does set the foundation to change how we do this, on a national level and a really on the [00:10:00] local level, but nationally really address this problem and part of that is TEFCA. And part  of that is RCEES and USDA. And I want to walk through that acronym soup with you. If so, let’s start with, 21st century cures and SCA, why is 21st century cures important? And what is TEFCA 

[00:10:21] Micky Tripathi: [00:10:21] Sure. Yeah. So 21st century cures was passe d just to give perspective to everyone who’s listening, that was passed at the end of [00:10:30] the Obama administration, which I know feels like about five generations ago, but that law, a lot of people confuse it with the cares act which of course was to address COVID.

[00:10:39] The cure is the 21st century cures act was passed. a t the very end of the Obama administration, and it’s only now coming into force because it took that long for the rules to come out. But now that the rules are out, what’s important about, about 21st century cures, I think is, I think of three things as being really important.

[00:10:56]One is tough guys. You pointed out tough guys, the trusted [00:11:00] exchange for air more framework and cooperative agreement and things what’s called. And that is, the creation of a nationwide framework for interoperability with a governance mechanism. And an approach to managing a dropper ability at a nationwide level, bringing the networks together, under a single governance, framework that’s work that’s underway.

[00:11:23] The RCE that you referred to is called the, the recognized coordinating entity, which is supposed to be the. [00:11:30] Organization that plays that governance role. That’s supposed to be the forum for having these networks. Let’s say, we don’t know how many networks, but with the find the standards that will define the policies working closely with the federal government to define what are the rules of the road of nationwide interoperability. And how would we think about that? That’s what the Sequoia project is the RCE right now. And there, hard at work, working with the, with the federal government, as well as with, with key stakeholders to develop that framework and develop that first set of [00:12:00] rules of the road, to be able to, launch that, obviously COVID has slowed things down a little bit.

[00:12:05] And I think one the, one of the interesting features of TEFCA is that it’s not required. There’s nothing that requires that anyone participate in Tufco. So that would be a little bit of an experiment here for us to figure out, how valuable is TEFCA to people because, it’s not like meaningful use. It’s not like the information blocking rule. there is nothing in the law that says you must connect to TEFCA. There’s nothing about payment. Let’s say it was, you [00:12:30] must be connected to a TEFCA eight health information exchange, in order to get paid. So that’s it. Yeah, that’d be an interesting thing. That’s, it’s going on. We hope that it’ll have a number of, large, participants network participants, like CommonWell and Carequality who will join that. And become a part of those networks, but it’s really an open question of, is that going to be something that accelerates interoperability or is that already happening on its own?

[00:12:53] And TEFCA’s a nice overlay, but isn’t, isn’t necessary to accelerate the market. the other things, The other parts [00:13:00] of, of 21st century cures, I think are really important, are information blocking. So the law, the information blocking law that, you know, that basically said to providers and to their vendor and to vendors, to EHR vendors, that your default should be to share information assuming that, it’s happening under appropriate permissions related to HIPAA and any other regulatory, constraints that might exist in the market, but subject to those, that the default should be that you’re sharing information and an [00:13:30] identified a certain number. I think it was seven exceptions. That you could claim for not sharing information, if it’s being requested by another, by another authorized party. but that really flips a little bit of the conversation. As you were describing with your experience with St. Joe’s, it was, asking to share information with another organization and they, say, no, I don’t want to do it. Now that kind of flips the equation to say they have to have a reason, essentially to say why they wouldn’t do it where the answer should be. Yes. right away. And so information [00:14:00] blocking is really important. It’s important for the providers, as well as importantly for the EHR vendors, because there’s real penalties associated with it.

[00:14:08]That could be enforced. So that’s a really important part of this. It’s a policy framework that applies nationwide. There is a draft rule right now. That’s about to be released. It could get released actually today or tomorrow that could delay the deadlines for information blocking, which I think would be, disheartening to some of us. but on the other hand, we are in a. in a national [00:14:30] crisis, I think a global crisis. so I think it’s certainly fair to think that in a global crisis, it probably makes sense to, to give a little bit more time to some of these things, given that provider organizations in particular, I have a lot of other things that they’re trying to focus on right now.

[00:14:43] The last important piece of 21st century cures, And then I’ll pause I promise, is the requirement would float from that is the requirement that, That we use FHIR restful  APIs in particular, a particular [00:15:00] version of FHIR  an interoperability standard that we can certainly talk about more, as the basis for, these interoperability paradigms that you know, that are going to be a part of the future.

[00:15:11] So up until that point, there had been no requirements for what would constitute, a requirement for interoperability on a nationwide level. and, and in particular for the use of restful API APIs or a specification for a restful API, and what flowed from 21st century cures was the most [00:15:30] recent ONC rule that said that you, that, in order to fulfill the requirements of this law, you actually have to implement a specific version of FHIR. so that, we have as close to standardization of API based exchange across the industry as possible. the other dimension that flowed from that was CMS, extending it to payers. Payers have never been part of this. And as you start to think about, the importance of saying that payers should be making data [00:16:00] available and interoperating in the same manner that providers have been required to is really an important part of extending the ecosystem, the interoperability ecosystem out to another critical part of the healthcare delivery system.

[00:16:13]Bill Russell: [00:16:13] And which version of FHIR did we end up at 4? 

[00:16:18] Micky Tripathi: [00:16:18] Yeah it’s a specific, implementation guide for our four. Yeah. So our four is what’s required. It was a particular implementation guide. That’s called the US Corp. It’s a [00:16:30] US Corps implementation guide STU poverty blobbity you could find it in the rule. but it was a version that was passed just this past September. And that is the rule that, or is the specification that’s required to be implemented both providers as well as payers.  

[00:16:44] Bill Russell: [00:16:44] That’s a great foundation for the 21st century cures act. I get questions from time to time. Hey, this USDA thing over here is that a part of 21st century cures? What part is that going to play in interoperability?  

[00:16:57]Yeah so the USCDA Micky Tripathi: [00:16:59] is a [00:17:00] really important parts of the USCDA is. a evolution of what used to be called the CCDs, just to throw another acronym in the mix, which was the common clinical data set. So the common clinical data set got defined as a part of the meaningful use program. And it was, basically, you know what we were getting, what was being said at the time was. There was a certain amount of information that we want to have captured in these CCDs that are required to be made available to, to providers, and provider to provider exchange.

[00:17:28]Let’s say as a [00:17:30] part of a referral for a referral, transition of care, for example. and then the question of, all right, I’ve got a CCD, which is just an XML document. What am I required to put in there? Is there like a minimum set of data? And the answer to that is yes, it was called the common clinical data set and it was about 21, 22 data elements that, if you and I, bill sat down naively and without any background in informatics and said, what are the things that we think most doctors would [00:18:00] want to have in front of them?

[00:18:01] So that next patient was walking in, we would on our own come up with 90, 95% of the CCDs. It’s very intuitive, right? It’s allergies, meds problems, right? very common, kinds of things that are contained in the common clinical data set. So when the new rule, the new administration came in and, and issued the new role, they basically, renamed the CCDs, the U S CDI.

[00:18:25] Which is the U S core data for interoperability, but it’s an [00:18:30] exact same concept. And basically said it’s a core set of data that’s required to be made available now through a fire API so that when I request data through a fire API from provider a, from mass general hospital or st Joseph’s or from Cleveland clinic, I will have the same expectation that when I get back, we’ll be at a minimum U S CDR.

[00:18:54] So I can at least count on that. And then they may, each of them may add more on top of that, but it’s the common [00:19:00] denominator that’s required of every API to be able to make that available. 

[00:19:03] Bill Russell: [00:19:03] Are we getting, are we getting discrete data elements at that point? 

[00:19:07] Micky Tripathi: [00:19:07] Yes. Yup. Yup. Actually we are, you know what I think one thing, for us to just, and this is a little bit of a salty of interoperability, but that’s what this stuff I guess is about. Right. Not just the superficial, but you know, but the deep, deep understanding, is that. Even with CCDs, which are required to be exchanged for certain transitions of care, under meaningful use and then promoting your [00:19:30] profitability. Those were discrete data elements as well. In the continuity of care document, the beauty of an XML document is that it’s human readable as narrative, or it can be rendered as human readable, but it actually has the structure data in each of those, in each of those sections. The problem with it is that. It’s really clunky. you get that whole document every single time. So you might just want labs, but you have to get the whole document in order to get the labs. And some of those XML documents can, if you were going to innate them could be [00:20:00] dozens of pages long. And you’re thinking all I want was the labs.

[00:20:03] That’s it. That’s how I didn’t want all this other stuff. So it’s really clunky. And it also was a real bear which was one of the things we can talk about, is how does this innovate the industry? Is that if you were outside the industry, you don’t want to be dealing with these weird XML documents, right? You want to be dealing with discrete data ones. So the data elements were always there, but in a very unwieldy and clutter form that, really was a barrier to better and richer and cleaner interoperability. The beauty of [00:20:30] the FHIR API is that it does allow that data element,  interoperability for me to just say, I just want the allergies. Don’t send me anything else. 

[00:20:39] Bill Russell: [00:20:39] Yeah, we’re going to go in a lot of those directions. I jokingly refer to this as we could rename this podcast tomorrow is the education of Bill Russell. So my job is to ask, some questions, that, just might appear like I don’t know what I’m talking about, but I’m really okay with that because with every podcast I get a little smarter. USCDI. [00:21:00] So that’s the core clinical data set. is the government gonna keep expanding that or do we anticipate that health systems will come together? Like they did in Massachusetts start to define other datasets around oncology and other things and are, will those all end up becoming a part of USCDI?

[00:21:18] Micky Tripathi: [00:21:18] Yeah, that’s a great question. So the answer to that is actually both. So the government is planning on expanding USCDI. Actually the idea of the USCDI is that [00:21:30] it’s a concept and it will continue to grow over time. So we start off with the USDA is this set of data elements, which were derived directly from the CCDs, the common clinical data set and that over time as we get more and more maturity and the industry gets has more and more demands in terms of the kind of data they want to have interoperable. The federal government through standards development process will add to the USCDI. So the idea is let’s not do that overnight because there’s a whole bunch of data.

[00:21:58] That’s not really, [00:22:00] mature enough right now to be made available in standards based ways. But as we push for it as an interest from an industry perspective, to make that data better in more standardized that at, at the point of maturity of those, then ONC would say, all right, for the next version two of the U S CDI, it will now include these additional elements. And the idea is that will continue to grow. And just to give you an example, of, how important that is. first thing to note is that the common clinical data set was defined [00:22:30] back in 2012, something like that as a part of meaningful use, it has not changed meaningfully since then.

[00:22:39] So here we are, seven, eight years later and it just got renamed the CCDs to the USCDI. But it’s only in this version of the USCDI that it’s changed. So it’s up from 2012 to 2019 or 2020. And let’s say it actually didn’t change. And you think about that, it’s lik wow, that’s really, [00:23:00] it’s kinda very static.

[00:23:01]So the idea is now let’s make this more done. Let’s make this more dynamic. We need to add more and more things to the, so now, clinical notes are now included for example, which is like, really important, data on their other data that now got added to the rest of the eye, but that’s the first upgrade to it. So that just shows that it’s been very static for a while and we really want to make it more as a growing thing. The second thing is that right now, it’s just clinical data that’s contained in there. So there’s no administrative or claims or payer related data in the [00:23:30] USCDI. So you talk about exchanging information, anything that you know, that a payer would care about like claims-based data, eligibility, data, benefits, data, explanation of benefits, data for patients, payment, none of those things are USCDI right now. So even as we think about these FHIR APIs, it’s like, Oh, there’s a whole bunch of data, but actually isn’t included in that right now because it’s so clinically focused.

[00:23:56] Bill Russell: [00:23:56] So payers are being required to share their data. Is that part of 21st century cares or [00:24:00] is that. 

[00:24:00]Micky Tripathi: [00:24:00] So it’s derivative of 21st century cures. So 21st century cures act law itself didn’t require that but CMS as they were, looking at ONC creating the rule to implement 21st century cures.

[00:24:14] CMS, really decided, I think, in what was a great decision and, something that was really beneficial to the industry just said, you know what, we’re going to lean way forward into this. And we’re going to say that, that, as a part of the regulatory authority that we have over any health plan that’s regulated by [00:24:30] CMS, which is not just Medicare and Medicaid. It’s commercial plans that are a part of the, ACA exchanges in every single state. And that starts to cover, a whole bunch of health plans and a whole bunch of the market. They basically said, we’re going to require that you abide by these rules that came out of 21st century cures because interoperability doesn’t work if it’s just the providers, the payers should be required to do this too. So it wasn’t explicitly required by 21st century cures, but through rulemaking CMS, basically. Put it under that [00:25:00] umbrella and said, we’re going to write a rule that says that, the payers need to abide by the principles and the concepts of, what’s the 21st century.

[00:25:07] Bill Russell: [00:25:07] Have we seen groups self-organize, is there an example of that yet? or are we hopeful that’s going to happen and where will that happen? Will that happen with maybe an academic medical center taking the lead or will that happen with, industry organizations taking the lead? 

[00:25:23] Micky Tripathi: [00:25:23] Yeah. And that’s a great question. And it’s actually all of the above. It’s already happened and you named some of those, [00:25:30] organizations when you were doing the intro. So the organelle project, the Karan Alliance. codex, gravity, let’s see. What’s, the DaVinci project, and a number of others are whether, what are now being called fire accelerators. So these are, the first one was the Argonaut project, which formed, in 2000 late 2014. And the idea of that was, it was, as we were looking out, Then looking at, fire starting to get a lot of attention and the very [00:26:00] high probability that, that the national coordinator’s office would make fire and restful API is a part of a certification requirement.

[00:26:07] A group of EHR vendors and large providers got together and said, we should, act ourselves without waiting for the government. To try to, get some market input into accelerating these standards, to make them as ready as possible once they reached the point of being required by regulation.

[00:26:25] So let’s, try to accelerate that and then, make that stuff more [00:26:30] mature. So that, it’s ready for prime time. Once it becomes, once it becomes ready, a part of regulation. And that I was really focused on a group of stakeholders who were like a coalition of the willing around us, a certain set of things, and it was focused on clinical care and, provided a provider exchange or provider to patient exchange, but basically like electronic health records.

[00:26:47] And what’s in electronic health records that ended up becoming, pretty successful that led to the creation of the requirements that are now in regulation for. Use of APIs and the use of fire, and led to, [00:27:00] for example, the specification that’s in the Apple health record. It’s based on the Argonaut project specification that got created, out of that but one of the things that we recognized as we were starting to, reflect on the Argonaut project was that, that not only the out the output of what we did was important, but it was actually the forum. the approach that we took that, and this was really just something that we noticed as we, it wasn’t as if we, have all this in mind at the beginning, it was more just, people getting together saying, Hey, let’s, take the next step and do some stuff.

[00:27:30] [00:27:30] But we recognize that, oh, this market-based thing is really important. And one of the things that’s really important is just having focus around something that you really want to do. And so that led to like the DaVinci project. Moving forward where you had a group of payers who said, we’re really interested in payer oriented use cases. And we want to focus on that part of FHIR, where that’s really important for payers and get together and collaborate among, competitors getting together and saying, let’s try operate around these standards to help move everyone forward. And so the DaVinci project then came and then the [00:28:00] Karan Alliance.

[00:28:00] So DaVinci has focused on payer type exchange. The carrot Alliance focused on commercial payers and patient access, from, from payers, first and foremost, but patient access generally. And then you have, the gravity project, which is focused on, on social determinants of health. You have codex, which has focused on cancer, data. just as you’re describing, there are a lot of these communities that are forming all with an eye towards saying, I want to accelerate this part of the FHIR world. So [00:28:30] that I can make it mature faster. Ultimately, not only for this purpose, but ultimately with one part of the goal, being that ONC would say, ah, that cancer data is now mature enough and standardized enough that we’ll make that a part of the USCDI. A nd so you start to get, that feeds into a process where the UFC starts to expand, faster than it would otherwise, because you have this market-based organic activity, helping to accelerate things that people find are important in the market. [00:29:00] 

[00:29:00] Bill Russell: [00:29:00] I was in some of those rooms early on where a niche would grab you or HELOC would grab you and say, Hey, come to this session. It would be, a side room for hymns and they’d be talking about FHIR and where this thing’s going and whatnot. but, that wouldn’t be the case today. The fire has a, an awful lot of legs and it even had it before 21st century cures. a lot of people were seeing the promise of it.

[00:29:23] And so I want to talk about two aspects. One is, do we anticipate this as the foundation for really a renaissance [00:29:30] in digital health that we’re going to open up this data to this world of developers and in collaboration with health providers and even payers and just see a whole new set of applications. That’s the promise of it. Right. and do we anticipate that happening? 

[00:29:47] Micky Tripathi: [00:29:47] Yeah. I think it’s already happening and I think it’s going to, really start happening and, exponential ways as we start to see that ecosystem start to form.  and I guess it’s a, [00:30:00] it’s an interesting question because, on the one hand fire is just a standard, right? So you would say, It’s just a standard and we have HL seven V2, and then we had CCV just a technical, 

[00:30:08] Bill Russell: [00:30:08] Because my alternative is I have to go through, I have to go through this app store and I have to pay significant amounts of money. it’s challenging. It’s difficult. It’s costly. 

[00:30:17] Micky Tripathi: [00:30:17] Right, right, right. Yeah. and, and so you ask yourself how could a technical standard. When you, as you and I discussed before this isn’t a technical problem, right. It never was a technical problem. It’s all about business, [00:30:30] and, all of the issues related to business and about, the socioeconomic climate of healthcare, not about the technical standards or lack of technical standards, but the reason that I think that FHIR itself actually is really important and we’re starting to see that is a couple of things. one is that, it’s a very, it’s really democratizing in a way, because it is much more aligned with the West with the way that the rest of the internet economy works. And so you don’t have the, as I was [00:31:00] describing before, developers, most of whom live outside of healthcare, right.

[00:31:03] As much as we like to think healthcare is the fulcrum of the universe. most of the internet, most developers live outside of healthcare and. Any of them who looked in healthcare and thought about making a step or two into healthcare, like Google health early on, they have the, the patient portal at Google health and one of the things, and then Microsoft health vault a little bit later. And one of the things they discovered in trying to work with CCDs, which were, the state of the art. Was, Oh, man, those are just like [00:31:30] painful. that is just it’s healthcare specific. It’s 1980s, sort of technology. And I can not get my new Stanford or MIT grad to agree to study a thousand page implementation guide of an XML standard.

[00:31:46] And they’re just not going to do that. There’s no way in the world they’re going to do that. and so they just stayed out, right. They stayed outside on the periphery. And, and I think if we’ve learned nothing else from the internet, crowdsourcing is everything right? The more [00:32:00] eyeballs and the more people you have working on stuff.

[00:32:02] The greater, the odds that really cool things are gonna come with it. and so it’s democratizing in that way. And then wrestle API APIs are the way the rest of the internet economy works and it opens it up in that way. I think the other thing that’s really important is that, it, because of the data the data element, a transaction that we’re talking about, it allows for really, refined and rich applications, that can be really targeted that things that, you know, that drive [00:32:30] people’s lives. An app that is just focused on your allergies with whatever other comorbidities you have.

[00:32:38] Right. And being able to, a developer to be able to create that kind of app that just tries to get that data. Any developer, who was stuck in a world where they would have to get a CCD every time and sift through 20 million  lines of XML code and all this other extraneous data that they didn’t want in order to be able to make that app work would say, [00:33:00] I’m not going to do that. there’s no way that I can make that app work. but if you tell them that there’s a FHIR API and the other end of it, and you can just get the data, you need to have your app work. I think that’s, that is enticing to people and is a part of that flourishing of that app economy that we’re just at the threshold of now.

[00:33:18] Bill Russell: [00:33:18] So the, let’s see, how do I say this? The arguments against, the final rule had things in it. Oh had people saying things like what about the Chinese hacker app, which is going to [00:33:30] you’re going to get me or my parents to download it. They’re going to get access to my medical records, those kinds of things. So there’s that aspect. The other aspect was, Hey, we just moved it from a HIPAA compliant data store, to Apple, which is technically not re not under HIPAA. And so that data stores outside of it. and have, are those arguments falling by the wayside or have they been addressed? 

[00:33:55]Micky Tripathi: [00:33:55] Neither. That those are really [00:34:00] big issues. And, and, just to, just to put a fine point on what you just said, because it’s a great question. That’s a really important question is when patients start to access the data on their own, say Apple health record, for example, one thing that, I think just to be fair to Apple, Apple does a fantastic job. Of making sure that patients understand what’s going on. Right. But they do that as a part of Apple policy. Not because the law requires them to, and there are lots of other actors out there who may not be as  good actors.  

[00:34:30] [00:34:29] Bill Russell: [00:34:29] I mean, Apple has stake their claim on secure. So that’s there 

[00:34:36] Micky Tripathi: [00:34:36] even, they don’t have access to the information. So Apple literally. Couldn’t tell you, if you ask Apple the question, how much do you know how many patients have downloaded their medical records onto their, onto the iPhone? They actually, literally can’t answer that question, because they’re not a part of that transaction. Right? So that’s all, between the device and, and through the API and, it doesn’t go through that central infrastructure, quite in the same way but the [00:35:00] point is that the minute that I, as a patient, download that information myself, it’s now no longer covered by HIPAA or no longer protected by HIPAA. That’s really confusing to 99.9% of people in the country. They think that HIPAA protects medical data. Right? Of course it does but HIPAA doesn’t protect medical data. HIPAA only protects the data that a provider has or another, or a payer has, when it’s in there, when they’re in control of it [00:35:30] and it covers their release of the data. But once it’s in your hands as a patient, if someone hacks in or you make the data available.

[00:35:39]One nightmare scenario REO is, you get the data onto your phone. Unbeknownst to you, you think it’s covered, it’s not. and, the data is now sitting there on your phone and let’s say, a recruiting app, you download a recruiting app as well. You’re looking for a job, right? And you download a recruiting app and the recruiting app notices, [00:36:00] in on the backend that, Hey, you have medical record data on your phone. Can we have, would you like to make some of that data available to the recruiting app, to demonstrate your productivity potential, to new employers and somehow it extracts information about some chronic condition that you have. And all of a sudden, you’re not getting any, any requests for your resume and you don’t know why HIPAA doesn’t protect that there is no protection. Actually the US, GDPR in Europe protects that, but in the U S there is no protection [00:36:30] against that. And I’m going to guess that the vast majority of patients have no idea.

[00:36:35] That that’s the kind of risk that they could face. if they don’t, aren’t really careful about their data, it’s a nightmare scenario, but that’s absolutely, we trade as individuals. We trade our security, our privacy for convenience all the time. Right. That’s what we do every time we, every time we do a search.

[00:36:51] We either know, are we trying to know, but we pretend we don’t, but Oh, I’ve actually got a beacon on my head as I go through the internet and Google [00:37:00] knows it and all these other places know it, but damn, I, I really want to buy that, that patio heater. So, I’m going to trade that off for the convenience. So just being able to order it and have it delivered to my door in the same way, you could imagine, the open table, I’m not saying open table is doing this, but, w what would stop someone from thinking about the great convenience if I had, celiac disease, or if I had, real food allergies, being able to say, Hey, I would love to upload that part of my medical record or give access to open table.

[00:37:29] So that [00:37:30] when I make a reservation, they tell the restaurant that, hey, this person has celiac disease, People do those kinds of convenience. Trade-offs all the time. It’s like, oh, now all of a sudden you’ve just allowed your medical record information to remain available over the internet with no protections.

[00:37:43]That’s the kind of, that’s that kind of concern people have. Just the last point the Carrot Alliance is working on, and has created a code of conduct and industry code of conduct. That the idea would be that well, there’s no regulation that steps in right now and protects that information outside of the [00:38:00] walls of HIPAA, but maybe there’s an industry code of conduct that you know, that we can get companies to sign, but at least we’ll have them in a non-binding way, but publicly committing to the protection of data that’s made available on their app. And that’s at least one step to try to close that gap. 

[00:38:16] Bill Russell: [00:38:16] And this is the brilliance of Apple’s strategy, right? So every time somebody, every time something tries to access the camera or access the microphone or access, or the medical record, I guess you would get [00:38:30] that, alert. And you’d be able to see that. And they might even have a. I know in the case of the camera, there’s a little, little circular thing that shows up. if an app is actually accessing your camera at a certain time. And so that’s the brilliance of their strategy is to know who’s accessing that. But again, that’s not a hundred percent of market share that. In fact, that’s only 60% of market share in the US. And globally, obviously Android has more market share and I’m not sure, because I’m not an Android user. I’m not sure what [00:39:00] their protections are against that kind of stuff. But I think we will. I, my hope is that we’re going to see an ecosystem sort of evolve that, puts a bubble around that information. Lets us know when we’re sharing it. So lets us know what pieces we’re actually sharing and I guess that’s the, the code of conduct and maybe we’ll see a GDPR kind of thing, in the US I don’t know.

[00:39:22] Micky Tripathi: [00:39:22] Yeah, I don’t either, but that is a big gap and it’s a real concern. that has been a concern for, for a few years now. 

[00:39:28] Bill Russell: [00:39:28] So you moved to Arcadia [00:39:30] t ell us about that move. What does Arcadia do? 

[00:39:33] Micky Tripathi: [00:39:33] Yeah. So Arcadia is a population health management and value-based care technology vendors. So what we do is we do analytics, and other applications to support, provider organizations, accountable care organizations, payers, and others who are in value-based care. Who are trying to, do everything they can to, move to, more value based purchasing types of approaches of healthcare, and to provide the foundation, the [00:40:00] analytic foundation and the application foundation for them to be able to do that.

[00:40:03] So being able to take in clinical and claims data, Analyze that patient data to be able to identify, who’s at risk. what are the risk stratifications? how do we measure quality in a better way? How do we identify, where there are gaps in care and how do we then deliver applications to those front, those people on the front line, like care managers who can then reach out to patients and help them,  come in and get the care.

[00:40:28] They need to be able to fill those [00:40:30] gaps in care. So it’s the end product to take data in and then deliver applications to the people at the front lines who make those kinds of interventions. 

[00:40:38] Bill Russell: [00:40:38] So are those applications like just a set of tools like AR and that kind of stuff? Or is it like, like a packaged set of, reports and, analytics tools.

[00:40:48] Micky Tripathi: [00:40:48] Yeah. it’s a bummer though. So we have, we have a couple of different ways that people can consume that information. So we have something, as you suggest, like our, we have a product called Foundry, which basically allows a [00:41:00] provider. It makes their data available to them so they can use whatever tools they want CQL or whatever.

[00:41:04]their own data to be able to do any kinds of analyses that they want to do with data marts that we create for them from their data. So they can do that if they want, if they have, in some of our, a lot of our more advanced customers will do that. They have their own data scientists who want to come in and just Wade through the data, which is, which is fine. we also have, reports that, that we can, publish on their behalf through a protocol bindery that basically. We’ll allow them to [00:41:30] define the set of reports that they want to be able to deliver to their providers, to show how their providers are doing on different dimensions of care and different measures of quality and performance, and to be able to distribute those to them in a static form that they can at least say, ah, okay, here’s my last quarter report.

[00:41:46] I can see how I did against all these measures. I can do benchmarking all of that. and we also have just, interactive, user interfaces that people can come in and dynamically look at data. so they can look at, the through applications. They can look at their quality [00:42:00] measures. There are cure man. There’s also a cure management suite that allows them to come in and. Look at risk stratifications, look at patients who are, create cohorts of patients based on criteria that they’ll define, or they can use the ones that we have predefined and then be able to say, all right, here are the high risk patients for certain types of risks that I defined.

[00:42:19] And now let me generate campaigns. For example, they can either have care managers on their own. Go out and do that work. Or in addition to that, they could generate campaigns to say, [00:42:30] here are the 353 patients who I know need a flu vaccine in the next three months. let me with the push of a button, send out an email to all 353 of those to generate that campaign, to try to bring them into the offices so it’s got, that full end to end capability with a wide variety of ways for them to be able to access data. and then increasingly what we’re doing is moving that to a platform so that people can actually bring their own applications to it. So they don’t have to use our applications. They can through a fire API or a set of fire API, [00:43:00] say. Hey, I, I love the way you curate data for me and the other value add that you bring in. But I have my own applications that I’d like to use. I don’t want to be stuck with yours. So we have FHIR APIs that allow them to do that as well. it’s 

[00:43:12] Bill Russell: [00:43:12] That’s interesting. That a lot of this stuff wouldn’t even be possible without the, interoperability work you did before. I assume you guys probably, you’re probably using HL seven. You’re probably scooping whole data sets as I would imagine you’re probably using FHIR. You’re probably using anything at your disposal to aggregate that data. Is that [00:43:30] pretty accurate. 

[00:43:30] Micky Tripathi: [00:43:30] Yeah. that’s a great intuition that you have, and it’s absolutely right. Customer experience as a CIO. You can’t say I’m just doing HL seven. It’s like, the world isn’t messing place. So yeah, we have a complete portfolio of PR of a whole bunch of proprietary connectors that we use. For places where, if you have direct access to the data to the database, like if it’s an on-premise EHR, for example, we can just connect it up with, on the backend with like an ODBC or SQL extract kind of software agent that can just pull the data out. That’s, [00:44:00] easy and fast. but increasingly, with more and more cloud hosting of systems, provider. Him or herself doesn’t have direct access to, or can’t provide direct access to their EHR. and as standards get better, we’re able to say, Oh, now we’re in a place where they just happen to be two CCDs.

[00:44:16] And increasingly FHIR will be approaches that can get us more and more of that data. Part of the challenge of that, as we alluded to before with the U S CDI, is that as you think about all the needs that are required for population health and value based care, [00:44:30] There was some types of data that aren’t a part of the USCDI.

[00:44:33] And, but that are really important to be able to, be able to do appropriate care. For example, scheduling data, it’s, hugely important, right. If I know the patient is coming in next week, and I know that patient has two gaps in care, you can imagine the importance of that to a care manager, to be able to say, get to that provider and make sure they know that when that patient comes in.

[00:44:55] Hit them up with, do you want a flu vaccine? And, do you want whatever else they’re missing [00:45:00] scheduling data as not a part of the U S CDI. So how do we, get that additional data out of those systems? Often it requires, separate types of approaches, HL seven V2 or even proprietary approaches or flat files. If we have to read something very mercenary and try to do it

[00:45:16] Bill Russell: [00:45:16] Chief Alliance Officer, what exactly is that? 

[00:45:21]Micky Tripathi: [00:45:21] I negotiate treaties, like that’s me and Churchill and Roosevelt and Stalin sitting at a table. [00:45:30] Now I really, I work on partnerships on strategic partnerships in particular. We have. We have a great growth team that works on what you would think of growth team works on, which is sales. And we have a great strategy team that works on the company strategy and somewhere in the gray area, there were things that aren’t about a direct sale. And then our pure strategy that we do internally, but you know, that our strategic partners relationships that we want to have with other organizations that are about long-term mutual share of [00:46:00] benefit or a set of things that we can go to market together with and so that’s what I work on. and part of that is with other companies, like we just announced a partnership with patient ping, for example, and, and with. Alvarez. And, we have an ongoing, partnership with, with AWS because we’re a big AWS user. So we have a number of those things and when we’re growing those and then, but it’s also the connection to those national level activities that you described before.

[00:46:24] Being able to, maintain, a presence in those national forums, like the [00:46:30] square project, like HL seven, to be able to, bring them that to Arcadia, but also helped to bring Arcadia’s experience to help that out better help inform, what’s going on at the national policy level based on the ground experience that we have.

[00:46:42]Micky, I wanna,Bill Russell: [00:46:43] I want to thank you for your time. T his is a phenomenal episode. I would probably go back and listen to it a couple of times, just, we covered so much ground and so much of what is going on today. So it’s, I’m really excited to have this conversation. Is there a way for, if people wanted to follow the things you’re doing and those kinds of things, [00:47:00] are you active on social media or other places?

[00:47:03] Micky Tripathi: [00:47:03] I am. Yeah. so I’m on Twitter. at Mickey Tripathi one I think is my handle. and certainly people should feel free to reach out to me directly. mickeydr. [email protected] and, and I occasionally blog on the historic site and then other places as well. So I’m very much looking forward to continuing the conversation with everyone and we really appreciate your time. Bill this been fun. 

[00:47:24] Bill Russell: [00:47:24] Yeah. Thank you very much. this has been fantastic. That’s all for this week. Micky was [00:47:30] fantastic. I hope you appreciated that show. don’t forget to sign up for clip notes, send an email, hit the website. We want to make you and your system more productive. Special thanks to our channel sponsors, VMware, StarBridge Advisors, Galen Healthcare, Health Lyrics, Sirous Healthcare, Pro Talent Advisors, HealthNXT and McAfee for choosing to invest in developing the next generation of health leaders. This show is a production of this week in Health IT. For more great content check out the  website thi weekhealth.com. Or the YouTube channel. If you want to support the show best way to do that, sign up for clip notes, participate in the [00:48:00] referral program. send it out to your peers and let them know that you’re getting value out of the show. Please check back every Tuesday, Wednesday, and Friday for more shows. Thanks for listening.