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Don Rucker, M.D.National Coordinator for Health Information Technology (ONC)HHS Office of the Secretary

Dr. Don Rucker, the National Coordinator for Health Information Technology, comes to the Office of the National Coordinator for Health IT (ONC) from the Ohio State University where he was Clinical Professor of Emergency Medicine and Biomedical Informatics and Premise Health, a worksite clinic provider, where he served as Chief Medical Officer.Dr. Rucker started his informatics career at Datamedic Corporation, where he co-developed the world’s first Microsoft Windows based electronic medical record. He then served as Chief Medical Officer at Siemens Healthcare USA. Dr. Rucker led the team that designed the computerized provider order entry workflow that, as installed at Cincinnati Children’s Hospital, won the 2003 HIMSS Nicholas Davies Award for the best hospital computer system in the US. Dr. Rucker has served terms on the Board of Commissioners of the Certification Commission for Healthcare Information Technology and Medicare’s Evidence Development and Coverage Advisory Committee (MEDCAC) and has extensive policy experience representing healthcare innovations before Congress, MedPAC and HHS.He has practiced emergency medicine at Kaiser in California, Beth Israel Deaconess Medical Center in Boston, where he was the first full-time Emergency Department attending, the University of Pennsylvania’s Penn Presbyterian and Pennsylvania Hospitals and at Ohio State University’s Wexner Medical Center.Dr. Rucker is a graduate of Harvard College and the University of Pennsylvania School of Medicine with board certifications in Emergency Medicine, Internal Medicine and Clinical Informatics. He holds an MS in Medical Computer Science and an MBA, both from Stanford.

Highlights from this episode

• Overview of current proposed rules and regs around interoperability
• Various technical topics, including APIs in the new rules; RESTful, JSON and FHIR
• the importance of the phrase “without special effort”
• Information blocking definitions
• How earlier efforts impacted where we are now and a discussion of how will know true interoperability has been achieved 
• Provider response to interoperability efforts; Changes in provider resistance; Interoperability as way to reduce provider burden and enhance the service array
• What interoperability means for patients, including Predicting apps that help patients interpret the new rich healthcare data AND Vision for transparency to improve healthcare for all Americans; and in important concept Dr Rucker calls consumer sovereignty
• bringing disruption to the healthcare IT industry
• Tensions between interoperability and HIPAA

NOTE: The transcript below is a rough approximation of the dialog and has not been cleaned up from the automated transcription service. It is meant to help listeners search/find for key topics. 

Transcript

0:03

Hi everyone. I’m clay Ferris to practice lead for Client Solutions and mostly Medicaid.com. You’re listening to our special series on interoperability and the healthcare industry. This is part of our ongoing project called critical conversations in Medicaid.

0:18

We interviewed experts from a wide range of roles to get a key perspectives on this topic while there are new regulations and rules by both CMS and onc our discussions deal more with the broader issues and challenges related to interoperability. I hope you enjoy learning from these experts as much as I did and don’t forget to check out the related issue brief. We did on this topic at mostly Medicaid.com.

0:41

A quick bit of housekeeping first, we would like to thank our sponsor for this series intersystems graciously made this project possible. If you’re not familiar with the intersystems, they provide a wide range of solutions to government agencies and Managed Care organizations to improve Healthcare outcomes and control cost. Please make sure to check out their work and learn more about what they do at enter systems.com slash Medicaid second. Here’s the disclaimer.

1:07

We intentionally interviewed experts with different perspectives and These they speak for themselves only and their inclusion in this series in no way constitutes an endorsement of mostly Medicaid or our sponsor. It’s also important to note that their opinions are their own and do not reflect the opinions of our sponsor now sit back grab a cup of coffee some headphones and listen to some of the most important insights. You will hear related to interoperability and Health Care Systems.

1:35

This episode features. Dr. Don Rucker. I learned a ton in this discussion. And dr. Rucker is a man of many insights. He’s also a funny guy which made this all the more enjoyable. I’ll let him give his bio in detail, but here are the highlights of his career so far. Dr. Don Rucker’s the national coordinator for health information technology as you might imagine, dr.

1:54

Rucker has an illustrious medical and health informatics career on the medical side doctor rockers practiced emergency medicine in California, Massachusetts, Pennsylvania and Ohio he was Israel Deaconess Medical Center’s first full-time attending in the emergency department on the health informatics side. Dr. Rucker started his career at data medic Corporation where he code developed the world’s first Microsoft windows-based electronic medical record for 13 years. Dr. Rucker was the chief medical officer at Siemens Healthcare. He was also the CMO for the work site Clinic provider / myths Health. Dr. Walker is a graduate of Harvard College and the University of Pennsylvania School of Medicine.

2:31

He’s board certified in emergency medicine internal medicine and clinical Informatics he holds an ms. In medical computer science and an MBA both from Stanford to give you a sense of some of the topics that we cover in this discussion. We talked about the overview of the current proposed rules and regs around interoperability. We covered various technical topics including apis in the new rules restful Jason and fire. Dr. Rucker has some interesting insights on the phrase without special effort. We also talked about information.

3:04

King definitions, we covered the history of interoperability and how earlier efforts impacted where we are now as well as a discussion of how we will know when true interoperability students achieved we talked about provider response interoperability efforts how those responses have changed over time and how interoperability is a way to reduce provider burden and enhance the service array. We also talked about what interoperability means for patients including predicting apps that will help patients interpret this new and richer health.

3:34

Are data that will be available to them as well as a vision for transparency to improve health care for all Americans and they think there’s this really interesting concept that we talked about related to this. The doctor refers to is consumer sovereignty.

3:48

We also talked about bringing disruption to the healthcare industry the healthcare IT industry and then we kind of ended on discussion about the tensions between interoperability and HIPAA. So you can see we’re going to cover a lot of ground in this discussion. I wanted to give you kind of some signposts of what we’re going to talk about. But without further Ado here’s the discussion the dr.

4:08

Rucker and I had Hi everyone. Thanks for joining us for this special series of podcast where we’re doing guest interviews with different folks in the space all about interoperability and we’re very glad to have with us today. Dr. Don Rucker the national coordinator at the office of the national coordinator of Health Information Technology. Dr. Rucker.

4:30

If you don’t mind just kind of giving us an overview of yourself your background what makes you tick just kind of fill in for our audience who may or may not be familiar with your Work sure. Yeah, so I’m somebody who trained as a internist have done emergency medicine on the clinical side of my career, but my interest in let’s call it information right dates to really before there was interoperability and in the as a med student actually in the late 70s was trying to figure out how to use information to make better clinical.

5:10

Visions when I got to residency this was actually at pain with John Eisenberg who was a very young faculty member then eventually headed the agency now known as Arc was influential and many folks careers the late John Eisenberg sadly when I got to residency I realized what was really missing was just data just making things moving things.

5:40

From paper to computers. This was very early 1980s the PC had literally just come out there. The Apple II had come out two years earlier.

5:52

And so at that point I took a bit of a career detour and decided to go to grad school in computer science also has an MBA while I was at it and was very fortunate to come a grad student at Stanford with Ted short-lived who invented rule-based expert systems in the very early days of artificial intelligence and have been in the field ever since was on the team that built the first Microsoft Windows electronic medical record. I would recommend that nobody ever try to build a product and windows 2.1 the long long time ago.

6:40

Most of the audience probably wasn’t even alive then but was involved in some of the major computerized physician order entry roll out. So I’ve been in the space and pretty much the whole time also been a practicing clinician in a number of big Enterprises Kaiser Beth Israel Deaconess in Boston University, Pennsylvania, Ohio State Stove involved number big clinical Enterprises as well.

7:10

As well. So have a lot of experience really with both what can be done electronically and you know the issues with using ehrs getting data all of those things. So that’s my background.

7:27

Thank you. Thank you. So you definitely your journey is definitely pretty extensive in getting you to what you’re doing today and just as a quick side note to give you always find it interesting for people came in and the technology story for me. My first computer was a Tandy 1000 HX that I saved up and bought from Radio Shack. I don’t know if Val. Yeah, and that was a classic s*** out. That was the first one that owns. The first one I remember using was an apple to G.

7:56

The in Elementary School playing the Oregon Trail and also learning Ms. Dots not on a level obviously but to be able to draw a picture of a brain of a human brain by pixel and Teenage Mutant Ninja Turtles those things like so it’s like so far far far back.

8:19

So we’re going to get into a lot of different discussions around interoperability and For folks that listen to others in the series. You’ll know that our you’ll see how we kind of go different perspectives throughout we ask similar questions, but I think dr. Rucker for you just because of the timing I think there’s some various and Sundry different proposed rules and regs. The last few years ones that are on the table. Now that sort of thing I want to make sure to give you an opportunity from your role at least for my audience.

8:51

If you wouldn’t mind kind of given the high level picture ER of I think the I guess the onc rule and you know, what are the main things you think are important for people to look at in those just kind of take that where you will before we hop into the rest of the conversation. Sure. Yeah Clay so in the very end of December, I well in December 2016.

9:15

So the end of President Obama’s administration Congress passed almost unanimously and then By President Obama the 21st century cures act and a number of members of the audience will probably know it for it’s freeing up of a clinical trial data approaches for the Food and Drug Administration, but there is also a big provision in there on interoperability and onc is charged with implementing that so what was it that Congress wanted?

9:53

It and what it Congress put in to the 21st century cures act and I want to say while that was passed by Under the prior Administration. I can absolutely assure you the President Trump the White House secretary Azar the Strait of Rome were obviously o&c.

10:11

We are totally behind that and in fact a lot of the language in there was you know supported with technical assistance from The prior National coordinators. So a Karen desalvo and been dealt Washington, I think pretty much it a broad-based effort. And what did Congress want?

10:36

I think what Congress really wanted is to get Healthcare back more in the hands of the public, right and specifically I think there was sort of a gnawing sense that we have computers smartphones in the rest of our lives, but we really somehow Don’t have access to our information and the richness of the app economy really anywhere in healthcare. I mean, we have you know, isolate things fitbit’s, you know, but we don’t really have that modern consumer connected instantaneous powerful access to our health information. And so and then there were a lot of other related issues on interoperability.

11:25

In part because of the way that you know, our Healthcare consist systems in the US have configured themselves based on the incentives they see but when Congress said is really three big components to further interoperability first, they did they heard the message that the various health information exchanges, which are roughly two-thirds of the country.

11:48

So Regional typically state level programs that they weren’t fully educating with each other or at all some cases and asked that there be a trusted exchange framework and a common agreement so that all of these folks essentially talk the same language and adding into that makes are the two large vendors have systems. They also started that are gaining some ground and having them as well so that the shared information is out there.

12:23

Are you know it’s so that providers can get information, you know, not repeat all the tests that type of thing. So that’s one big thing.

12:33

The second big provision is a Prohibition against information blocking and again, I wasn’t there at the time but I think many people realize that that way we’ve invented the structure and Health Care is really for Very large Delivery Systems to be built up and become so dominant in their market area that the payers basically have to take whatever the prices and then that is passed on to the speciality folks in commercial health plans and their employers and that’s been you know the mode of doing business and that does not of necessity.

13:22

That’s not a Information sharing model when you think about it, right the incentive there is to quote unquote prevent leakage of the patient and to not let the patient’s really shop for care experience choice but to keep them in the network. So Congress said it is illegal now to do information blocking the patients have access to their data and that you can’t just not share because that is you know, your business model obviously every business.

13:53

On some level would like to make sure that customers never go elsewhere. I’m sure you know Target may see, you know, Amazon Kroger picture, you know, what all like to cap through the customers forever and ever but that’s not obviously the way that a competitive market and choice should work with the American tradition. So Congress said, you know what this is illegal now, I’ve see there’s a lot of nuance here, which we’ll talk about.

14:23

I’m guessing but the third big part besides the trust exchange framework for the health information exchanges and the prohibition against information blocking. The third part is really how do we technically get these things to interoperate?

14:40

And what Congress said there is actually very elegant obviously Congress is not a group composed of computer scientists and network Engineers, but Congress said and I think think at the right level of granularity that providers of electronic medical records in these networks and the providers they need to have what are called application programming interfaces. So in computer, you know, jargon apis and that those should be usable and here’s the key phrase the key phrase the Congress came up with is without special.

15:24

So what does without special effort mean? Well, it means really, you know standards based API so that these applications the electronic medical records interoperate and potentially with new apps and you know coming in from the app economy. This is historically not been the case in healthcare the apis and Healthcare have been while they’ve had some standards.

15:52

They’ve tended to be More customized bespoke standards unique to healthcare and frankly a bit idiosyncratic in terms of how to actually use them. So there’s a little bit of a black magic involved these days. The rest of the world actually knows how to hookup apps and Enterprise databases quite well that technology has over the last 20 years Advanced a lot.

16:22

So if you use an Burr or Lyft app that app is going against all kinds of apis to get you your ride right? It’s going against a map API. It’s going against a credit card API. It’s going against traffic API. It’s going against an API that rates the drivers.

16:47

It’s going against the API that rates the passengers right any app that you’ve ever Use that uses a map in there right restaurant reviews. Where is this restaurant? Where’s the nearest pick your you know Big Box store, right? You can look all of the big box stores have you know, you can find them on the map, you know Home Depot, you know Staples Target, you know pick here pick your store, right? Those are all apis.

17:17

So We don’t have that kind of access and health care. So Congress said apis without special effort.

17:25

So what we’re doing in a rule that is there’s a as folks May into it a very Heavily prescribed Federal rulemaking process that has multiple Cycles we’ve gone through the public comment phase or notice of proposed rulemaking. We got two thousand comments back on a role that basically puts out and will be finalized soon here. You know, what does it mean for?

17:58

Information blocking what does that look like? What’s what are allowable behaviors are that you could argue might be information blocking. What about how the apis work? How do we test for those? So that is those are the key things in our interoperability rule. It’s there’s some novel legal ground on, you know information blocking certainly that you know is not really typically been an issue.

18:27

Other sectors of the economy but is in healthcare. So that’s out there CMS has a companion rule that they’re using their payer authorities for directed at a requiring the various payers participating in Medicare to provide apis on claims data as well amongst other things, right? Thank that in a nutshell are the or the or the interoperability ruled.

18:55

Thank you very much. Very definitely gives a pretty good context. I think for for any any folks listening of how it got there and what I think the vision was, yeah, so thank you. So, let me step back a minute. I think you know, I know I know my audience as Technical and non-technical folks technical being folks that have been eating sleeping and breathing interoperability for decades.

19:24

Nickel, you know sometimes maybe like I was even a year ago. Just trying to even pronounce the word interoperable correctly. So in a lay person since how do you define interoperability?

19:39

Well, you know, I think.

19:42

Interoperability, I think has sort of maybe two things the layperson would see one they would see when they’re a patient that there’s a relatively seamless sharing of data amongst their various providers, right? So that would be one one level right? You don’t have to repeat the MRI. They know what surgeries had the med list your allergies. You don’t have to tell them again, you know.

20:12

Yeah, I have to fill out the clipboard. You know, when you go to the doctor’s office, you know, blah blah blah, that would be one level of interoperability. I think in the modern world.

20:27

The true test of interoperability is can I on my smartphone get my medical data and then can it be surrounded by apps that make it convenient for me to go about Getting Healthcare shopping Health Care, maybe even more importantly just staying healthy be in control of of my situation and having new options. Totally new products. Right? I mean I could maybe have some kind of a product where it knows what my meds and problems are and then somehow independently gets a blood test or saliva test and tells me are those things optimized for my physiology, right?

21:12

Are things that elegantly combined my medical record at various providers and tell me you know, what are the three most important things that could be done next for me to live longer or just some convenient reminders about you know, what what vaccinations I’ve had which ones I might want to have.

21:36

You know all of those types of things and you know, the sky is honestly going to be the limit here, right? There’s a lot of consumer grade things. I mean, you know, certainly it’s maybe not totally consumer-grade but you now have ultrasounds that hook up to your iPhone now is they’re not licensed for non non clinicians to use it. I have one they’re amazing, you know image quality, but I think it’s a an amazing world.

22:05

We’re going to see so I think the real interoperability goes well beyond the providers have my medical record to has my medical information been integrated into apps of my choosing that reflect my life needs. That’s the real test of interoperability. That’s what we’re targeting. And of course that is powerful not just clinically but frankly as important giving the vast sums of money these two countries spend on Healthcare.

22:35

Economically, right your audience sure shops online and I’m pretty sure when they shop online they want pretty intelligent description not just as a product but of the price just think in American Health Care, we know almost nothing about the product and we rarely know the price. Right? Right.

22:58

So that gives you a sense of where interoperability has to go right and it’s interesting because Most of I think when I started out doing the different guest interviews, we’re not planned and prepped this question. How is expecting? Oh, well, this file format needs to work with this or you know, this system needs to par whatever without exception I think including yourself, you know, folks have pointed towards it. No, it needs to be at will know it because this is what will look like for the member for the patient for the human.

23:32

These are the things that will be Accomplishable, you know, I mean it it’ll be like that famous quote by Potter Stewart the Supreme Court Justice on the definition pornography rise, you know, I know it when they see it, right exactly. You know, normally we don’t quite viscous action about pornography but you know since was a Supreme Court Justice will go with we’re good.

24:05

Yeah, you know, I think we’re just simply not there yet. Right. We’re not we’re not there yet and the consumer right in this world you want, you know, you’ll have your MRI on your smartphone. You’ll have all the MRIs that were ever done on you on your smartphone. Right? I mean there will be and you know, there’ll be new ways of looking at your body to prevent stuff mean it isn’t widely used now, but we have cardiac CT angiogram that essentially can prevent all heart attacks.

24:35

Current technology rarely used not not offered in the current scheme of life in the consumer empowering way. There is much we can do to have ourselves with you know, healthier lives, even if maybe where you know, not fully up to where we should be in terms of fitness and dieting and all that good kind of stuff right?

25:01

Let’s let’s take a little while longer on sort of kind of History of or the leading up to efforts of interoperability and then I want to hop into some perspectives. But it in your when you’re at about your background, you talked a little bit about kind of where you hopped in or where you see interoperability kind of beginning in your journey.

25:22

I’ve had one of the more interesting examples I’ve been given was a former State CIO of a mental health agency talks about when he took the helm in maybe Maybe I think maybe the late 80s. He was handed a giant binder full of paper about the latest interoperable Workshop strategy that his predecessor had been too but I mean everybody’s kind of got a something they point to to say. Okay. Well, this is how long I think we’ve been trying it. What do you point to like? What is the first major effort? You can think back on to achieve? What were what we’re still working towards today?

26:04

Yeah, and I think the I’m told I did the sounds true. I that the the what is called the TCP IP stack, right? So the right software that is the computers backbone of access to the internet that wasn’t part of Windows until Windows 95.

26:28

And you know before then, you know, there wasn’t really, you know was it was proprietary interoperability again, there’s a history of networks and things like that. But it really I think the watershed moment has been in that era from 95 to roughly 2005 when we really started having Broadband to the consumer population.

26:58

A shh right right that I think you know, which initially of course was dial-up modems, but then, you know started becoming cable. I think that’s when we realized that we could have that we could have this and almost in a well somewhat simultaneous way, you know, we now have enough computing power. We now actually with the various programs.

27:28

Alms to incent electronic medical records. We now have enough clinical data. So the computing power of the clinical data, we’ve always had the algorithms and now I think we really have the networks and maybe the final piece of this is some relatively easy API technology software standards sitting on top of all of those.

27:51

Those are for the technical folks are called restful capital r capital e capital S capital T. Lowercase ful. You can Google that and Json the JavaScript object notation Json with the healthcare add-on called fire not as in the flame, but fhir fast Healthcare interoperability resources, though, of course, the land of a thousand tons since computer geeks can’t resist a made for hon acronym like fire.

28:28

But you put that thing together and now we really have everything we need other than arguably some of the political incentives to richly interoperate if that’s in fact a verb, let’s say it is it was coined here first. There’s nothing to say that yeah, we made out of but anyway, so so let’s in a way it was kind of sexy use that to segue into talking.

28:58

About the provider Community. Obviously, you yourself a physician, you know, I don’t know with with your own role. You’re obviously more advanced in your knowledge and Adoption of all these things and probably most of your peers but what do you think? I have a question here about providers and interoperability and how they really look at it.

29:24

I mean is in the general to the extent that we can the Other community do they really think making an all these systems they have to use more interoperable is going to improve outcomes. What is your what is your feel on that? Yeah. It’s obviously a nuanced question right? Because this is this hits providers and many many different ways, right? There’s the simple interoperability. Oh, I’d love to know what kind of pair that, you know cared this person got sitting.

29:58

front of me or on the stretcher in front of me, you know, there’s that I think there’s a frankly a deep concern that if all of this data is somehow magically available then I somehow will be required to know it all right to have read all of it, which is obviously an impossibility if you have a sick patient To you know, if you sort of just assimilate all all of this data, and then I think there are you know, just the natural human anxiety. If you have to do something that’s new and different right people understand, you know, I think clinicians hospitals doctors certainly can Intuit that the consumer empowerment.

30:55

man of the modern internet has upset a lot of different business models, you know, whether that’s You know airline ticket counters travel agent bank tellers, you know brokerage firm employs anybody who works in retail, you know, I think we all understand that, you know cab drivers, you know, we understand that they’re you know these things bring change.

31:26

So there are there are a lot of different things that I think are going on in the There’s had and you know, frankly we’re early, right they the products that do this. The integration is early. We’re just really starting with this I think over time all of this information whether it’s facing a clinician.

31:51

Let’s say who’s seeing a patient new but a patient who otherwise has information on the network or available or a patient trying to make sense of their The components of their medical record. I think they’re going to be absent help interpret all of this. Right. I mean, you know, that’s what the world is about. You know, we have you know, when you want to find something on the Internet, you don’t just search every internet node and see if it’s there. You used an app that helps you to search for it called Google. Right? Right. So Google takes from the entire internet and summarize it.

32:32

I’m sure there are Equivalence and health care Ryan. I mean I think about even even non app. I mean what you’re talking about away is the inside layer and a lot of that it for the member and a lot of that’s even things like Mayo content or Adam cons, you know things that help clay the member understand.

32:52

What is this thing that my physician just told me but this is but this is interesting now clay because those things are static and uninformed by not College of you as a patient. Right? Right, if you take start a static content a quote book.

33:11

Now we can do so much better because the computer can do what are your medical problems? What’s your age? What’s your sex? What medicines are you on? What allergies do you have? You know what what has been stated in your nose. So the information we can potentially act on now is vastly more specific and helpful than then just looking at books made electronic.

33:39

Ver I that absolutely makes sense.

33:42

I just think I was building on what I heard you saying about patients are still going to need help interpreting this and I think that’s a whole nother Frontier because the things you’re talking about will make those books not sufficient, you know, I’m going to want to know Go ahead. I mean one one helpful example for folks to think about is whether right so lots of people have weather apps. I think I have four or five of my phone and write they all pretty much use the same data, right the federal government provides there, you know, the NOAA National Oceanic and Atmospheric Administration. I believe they’re all using the exact same data, right?

34:25

It’s not like the weather channel has its own satellites from right so They’re using a federal feed of data and interpreting it in a way now, you know, you know and people can choose white interpretation what form factors they like how that’s embedded. You know, you know that embedded is it just straight up weather app has been embedded on it, you know on it in a ski resort in a weather prediction is it, you know better than a travel app somehow and it slips through all these things can be integrated.

35:01

But before we leave providers just one more question and then I’m going to kind of move on to the technology side of this the technology space and vendors things. But do you think if you look at where maybe how you might have answered that question 10 years ago over you think I go back to like meaningful use and some of the resistance that was there and all the new quote unquote burdensome things about implementing an EMR or now. I need a whole new.

35:29

Staff member. What do you see provider is assistance to the extent that it’s their lessening in recent years. And if so, what do you think is is making that lesson?

35:44

well I think part of it is, you know, the original meaningful use requirements, which is you may remember or part of an economic stimulus program, right? They weren’t really per se about emrs doctors or patients are about spending a whole bunch of money to jumpstart the US economy. You know, what could go wrong there.

36:11

Right. So that was the original thesis of it which from an economics point of view.

36:18

You know, I don’t think you can say Keynesian economics is exactly been the best model to explain the world over the last was it 90 odd years since John Maynard Keynes was around And in healthcare, you know it had you know, that issues that have been well well documented.

36:42

First of all, I would say both CMS and onc have done a lot of work to really take the pain out of a lot of these things obviously some of this was put in because people wanted to be stewards of the tax dollars and you know generate value in American Health Care, right? So that CMS is actually getting a deal for the public right? So it wasn’t a doctor she was much it was what’s good for the public. So there are a number of historical things to sort of remember as a backdrop to these programs.

37:20

I think when you Look today both the CMS focus and our focus is really increasingly on what are the underpinnings. We need to get the electronic health records to talk to each other and to get this information out to the public. So I think that’s been the focus. We’ve designed the role to basically once you have those endpoints up as a provider.

37:51

The system sort of runs itself.

37:54

Alright, you use the the way it would work in the proposed rule is you pick an app or apps of your choosing they go to the at the end point that URL of the provider and then in a very secure protocol called oauth 2 you use the exact same authentication you might use now to get it onto your doctor your hospitals web portal and use At to download the information to a smartphone app of your choosing all of that other than obviously standing up a server which you know is work, but we anticipate will be done by the HR vendors for the docks and hospitals.

38:40

You know for the smaller doctors and hospitals the larger ones I’ve seen set up servers and points without problem.

38:48

You know, it’ll be an endpoint that once you’re authenticated you can download your medical record from so we think it is innately less burden, you know, there may be questions on patients may have questions on what was done but by the same token Doctors and community may see this as a way to provide new services and different services and better services and frankly, maybe even more profitable Services, right? There’s nothing that this world is static and I think you know, the winners are going to provide sticky services on that. There will be branding around that, you know, you saw the Mayo Clinic just hired John honka to lead their you know consumer-facing.

39:40

Tronic efforts. I think you’re going to find a number of the big brand names are going to be quite you know, heavily involved in figuring out new ways and new services for the public. So let’s let’s talk about that because I think right and I’m glad you brought up how other disruptive type forces to and and how I hear you kind of emphasizing in a few different ways.

40:08

There’s nothing that says all this stuff has to Static, you know things change Marcus change vertical change Healthcare is no different. You know there there is an existing state of play. There are incumbent large vendors and and small vendors that are trying to break in and you know interoperability. I think in some ways will will this is just my personal less informed opinion than most of the guests on this I think interoperability will help the little guy a little gal.

40:40

In terms of vendors and I just don’t see how it’s a huge help for legacy. Very large vendors who don’t make those types of changes. And in fact, it’s like financially it’s not good for the larger ones. How do you view that? I mean is the answer? Well, I don’t want I don’t want I don’t put words in your mouth. How do you view sort of winners and losers in increased interoperability from the technology vendor lens? Yeah.

41:09

Well, I think the beauty of a free market and consumer sovereignty is that and we really don’t have consumer sovereignty and Healthcare. Right? Let’s be let’s be real, you know, most Healthcare still purchased by Third parties, but as increasingly as our deductibles rise, as you know, High deductible health plans, I mean, even the average Medicare beneficiary spend something like a hundred thousand dollars out of pocket over the course of their Medicare lifetime.

41:39

Um, so as we shift more and more costs back on to the public, you know, you’re going to have consumer sovereignty and you know, people will have to compete with they haven’t really or had to compete on just very narrow things.

41:56

So I think there will be a shift to a more consumer-facing health care that we haven’t really had since you know, 1965 and the Advent of administrative prices Medicare and of course are funny pre tax payment system that you know allows Al, you know banks in vast amounts of inefficiency, you know and removes large amounts of the spend effectively consumers.

42:26

I think that those World forces are slowly changing and you know that will you know winners and losers will check out some of the winners will be incumbents. Some of them probably companies.

42:43

We’ve never heard of right right and you know, that’s that’s just the way it is that you know, I think that’s the way it is the current business model where you know, just merging and buying up every hospital in sight.

43:04

Obviously some of that may be at risk, right because those business models assume essentially there’s no competition anywhere in right that all services have to be purchased as a And all first of all, I think you see legislative action to unbundle services, but you know, that’s sort of you know, how the app economy Arbitrage has things. So this is also related, but I think it’s this is moving us towards the information blocking questions that I have but in my view all this is proven that like it is proven that interoperability.

43:48

Ability has been achieved when I as a patient can walk into.

43:54

Really anybody that’s using my data if that’s a hospital my PCP, you know take this all the way out my local CVS or whatever and I can say I want to access all my Healthcare data right now, you know and it and there be no delay and it’s poured it over to my phone or whatever. I mean to me that’s the proof in the pudding right and when that when that but when that button can be pushed and I get it that means okay things are interoperable and nobody’s blocking my information, you know.

44:23

And I have access to it. And so to whoever I want that kind of stuff Ya Allah. I mean, how long is it until we’re really there. I mean, I know there’s some markets that are ahead of this and more versus others. I know we’re working on the regulatory framework and the incentives but if you had a crystal ball, how long is it until well any patient can do that?

44:46

Well, so I think In the current proposed rule that core data set would be would be available two years and you know standard space two years after the rule is finalized. And you know again, that’s a view where you download your data from a specific provider.

45:10

When you look at the broader thing of integrating data from multiple providers when you look at What are the apps that are coming off of that data? That’s probably a little bit further away. But on some level this stuff is quite doable because Apple’s healthkit is doing it as we speak. So Apple. Okay uses the you know, the fire standards at onc helped Pioneer. And again Apple never unless you store it on iCloud never actually sees the data apple is a security bro.

45:48

Between you and your providers, but they can help you get that data from the participating providers. So I think some of it is there now to that extent. Right? Right. So increasing availability of that of that benefit, I guess is really what we’re looking at verses building something brand-new. Yeah. So let’s talk a little bit. Let’s kind of this kind of close out our overall conversation.

46:18

In a little bit with a discussion on the information blocking and then I’ve got a question related to Turning. I don’t say turning the corner but related to how this might relate to HIPAA to and it will cover that one in a minute but information blocking if I’ve got it right at least in the general the general things that are being proposed. There’s Financial penalties if someone is if an entity is found to be information blocking and there’s also some sort of out of for lack of a better.

46:48

Term like a shame list or a blacklist which of these are do you think will have the most impact in terms of Clays organization writers list versus don’t write a check.

47:04

Yeah, so there are some specific legal language are so the 21st century cures act. So the law as we speak today is that certified electronic health record developers health information exchanges health information networks and providers shall not information block that law asks us so and see well the secretary delegate to us allowable exceptions.

47:34

to to that and those are things like, you know, you don’t have to share the information if there are no known specific privacy or security issues, you know, if there’s obviously some computer downtime but again, it can’t just be I don’t feel like sharing it has to be, you know specific and then one of the biggest complaints we’ve gotten is that some of the vendors charge Fee so high as that the fee level itself is information blocking. So we’ve put in some language that allows the vendors to recover costs make a profit. But you know the charges after be you know, you know reasonably related to their cost of doing things. They can’t just say, oh I might want to compete in the space.

48:30

I’m not going to allow any app to hook up to our Hospital product here that type of you know that type of behavior which the ground many many complaints so I think all of those things will play out but it’s early right? So this is kind of my last plans question, but do you see any inherent tensions between I think going into this?

49:03

Focus on opening up Clay member data, obviously for lots of good reasons, but coming from, you know, a couple of Decades of keeping Clays data.

49:19

I’m simplifying locked down right under HIPAA HIPAA and privacy and there’s a whole other discussion about I think the market has sort of implemented HIPAA in a way that it was never intended in a lot of cases that Kind of stuff but there seems like there is a little bit of a logical tension. Not that it’s bad between interoperability opening up information flow and HIPAA logically slowing it down. Do you have any you have a take on that?

49:49

Yeah, so so yes, there is a tension between the individuals right to get at their data and you know, quote providers protecting the data and then in this modern world, of course, we haven’t figured out the broader use of secondary use of data, right you don’t forget most health information about you that is economically powerful can be gotten without accessing anything anywhere in your medical record.

50:22

You can infer that from your GPS location. Oh, I’m always at the liquor store. I’m always at McDonald’s. I’m always at the gym. You know, I’m running a foreman Mile right most on my accelerometer says, you know have Parkinson’s disease, right? So most information about health care the vast bulk of of it sits outside of the electronic medical records under HIPAA.

50:52

Eric Lee HIPAA has been really facilitate treatment payment and operations this the famous TPO and that is done under a blanket consent. Basically that you sort of sign when you visit the doctors off office or the hospital. We’ve not had a lot of issues. It will also has a right of individual access in the past. This meant is medical records obligated give you a copy.

51:22

Chart, yes now in electronic world that means, you know, can you get your data to your app? So this is really a brand new world. There’s the tension between you know, what’s called secondary use of data with this app sell the data, you know under the work we’re doing on the proposed rule. There will be, you know, an informed consent process.

51:48

It’s much more helpful and real than the you know, End user licensing agreements we click through daily. But then again getting the data onto an app is going to be a very specific volitional process is you have to authenticate at your providers portal. So there’s nothing simple about that. So yeah, I think there’s a bit of a tension.

52:14

However, The real issue is not interoperability its affordability. The real issue is getting American public get a decent deal on Healthcare. Right?

52:24

Can they find out and price what they’re getting and I think if you ask any consumer, that’s not true for the trade groups who have entrenched business models that they’re very happy with and want to protect but if you ask a consumer should you should you the consumer be allowed to choose whether You can get download your data on an app or should the incumbent providers who are not transparent about either their prices or the you know, the product they offer be allowed to choose on whether you get your data.

53:03

I think we know the answer to that is pretty damn clear, right, you know, but you know, it’s it’s Washington so, you know No many people focus on quote protecting the patient. I’ve noticed that the focus on protecting the patient seems to be almost linearly correlated with the lack of capacity in the business model and pricing of the people playing protecting for heavily. I’ll lead you to drop there might be any conclusion there anything. This has been really wonderful for me. Thank you.

53:45

Taking the time anything else you want to kind of leave with the audience before we close. Yeah, I think you know the message is this Administration. We really want to empower the American public to shop for care to have information to know prices that there’s you know, we want to bring transparency about both the services and the prices into the American Health Care discussion for all of us employers.

54:15

has the government individuals to be smarter better consumers of healthcare and you know, as I think it was Benjamin Franklin make make our cells closer to healthy wealthy and wise Thank you so much. Dr. Rock. I really appreciate your time today. Thank you. All right, nice talking with you clay you to. Thank you.

54:41

That’s it for this episode in our series on interoperability in healthcare. Thank you for listening. Don’t forget to check out more of our great content at mostly Medicaid.com including the issue brief and other interviews in our critical Medicaid conversation series, and don’t forget to visit enter systems.com to learn more about our sponsor until next time.