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Episode#7: Interview with Elena Nicolella

Guest bio

Elena is the Executive Director of the New England States Consortium Systems Organization (NESCSO), where she has served for the past 4 years. Before her time at NESCSO, she played various roles in Rhode Island HHS agencies, including Medicaid Director.

Highlights from this episode

  1. Defining interoperability in terms of the CMS final rule.
  2. Defining what data the rule requires to be shared by Medicaid agencies, especially around adjudicated encounters/claims
  3. Member identity verification for data exchange in third party applications
  4. Limits to states’ authority over whether to provide data to 3rd Party Apps, or what happens after the provide it
  5. Expected member interest / appetite for more access to data.
  6. Impact of expiration of the HITECH Act funding
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Episode#6: Interview with Ed Cantwell

Guest bio

Ed is the President and CEO at the Center for Medical Interoperability. He has served in that role for the past seven years. Before that, he has been in executive leadership in multiple technology companies, particularly in the wireless and telecom industry. He also spent 11 years in the United States Air Force.

Highlights from this episode

  1. The critical goals of building a trust platform and data standardization; HIPAA as barrier to trusted health system
  2. 21st century cures act use of open API / forcing more exchange
  3. Differences between federal policy approach and industry association approach to trusted exchange and data standards
  4. Overlap of CMS/ONC efforts
  5. How meaningful use morphs into interoperability
  6. Issues with proprietary data and interoperability; information blocking as a concept
  7. How pressures on providers from various regulatory bodies makes it hard for providers to embrace yet another paradigm change
  8. The idea of surveillance capitalism
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Episode#5: Interview with Roger Hebden

Guest bio

Roger is the CEO of Livanta, which is a Medicare Quality Improvement Organization (a QIO). Before his time at Livanta, Roger has spent more than 20 years in IT and healthcare space, including roles at Microsoft, Dell, and Sutherland.

Highlights from this episode

  1. How medical records still are sent via snail mail and fax as primary mechanism for Medicare QIOs
  2. FIHR, BlueButton 2.0
  3. Using member education in an interoperable system that helps patients manage medical records
  4. Improving communications channels, including the limits of telephones and the opportunities with secure text
  5. What we make available vs what people use
  6. The limits of provider portals

the journey to appropriate consent management

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Episode # 4- Interview with Mary Alice Hunt

Guest Bio

Mary Alice is the North American Solutions lead at IBM Watson Government Health and Human Services. She has spent nearly 20 years developing solutions for state clients that focus on integrated eligibility, care management and healthcare reform. Before her time at IBM, she taught information technology at the State University of Albany, led product development at Curam and helped to modernize New York State technology systems.

Highlights from Episode

  • How quickly technology is advancing and the impact that has on interoperability efforts
  • Multiple challenges in interoperability, such as
    • Challenges of integrating various types of data being integrated before we are even ready for it in the private sector, and in government world it lagging
    • challenge of different terminology for same information
    • challenges in matching patient records
    • how our patient identifiers change over our lifetime
  • A plain language explanation of APIs
  • Various topics around patient data access, including:
    • Providing patients with meaningful insights about their health using their data
    • Challenge of getting data to Medicaid members
    • Challenges in consent management
  • Importance of starting with the right data model when designing consent management functions
  • Key data governance and design insights, including
    • designing for exceptions
    • making sure data is shared but not propagated; using a central repository model
    • challenges of converting data from old system to new system
  • 360 degree views of patient data in an interoperable system
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Episode#3: Interview with Kris Vilamaa

Listen to the Podcast

  • Guest Bio
  • Show notes

Kristopher VilamaaCEO, HealthCare Perspective, LLC & Senior Advisor to Mostly Medicaid

Kris has over nineteen years of behavioral health, health information technology and health policy experience. Kris has led major state system transformations including planning for Medicaid Transformation,  development of new behavioral health treatment standards, service definitions and leading large information technology system implementations. He has worked with state and county health departments, managed care organizations, community mental health providers, behavioral health county boards, federally qualified health centers, safety net hospitals and large health systems to enact meaningful initiatives.

Prior to joining HCP, he was Director of Behavioral Health for Germane Solutions and the first Chief Information Officer for the Alabama Department of Mental Health.

Highlights from this episode

  • Thinking about interoperability beyond just technology
  • How policy changes have been the drivers in our efforts
  • Prioritizing front line care delivery systems for interoperability first
  • How MITA impacted the push for interoperability
  • How the HIEs impacted our understanding of what we can do with interoperable systems
  • How old ways of thinking from legacy vendors hinders interoperability
  • How state agencies were the conduit for provider adoption incentives in the past, and how they need to think about their role in the next round of interoperability efforts
  • 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. 


    Hi everyone. I’m clay Ferris to practice lead for Client Solutions and mostly 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.


    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 enjoyed 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


    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 inter slash Medicaid second. Here’s the disclaimer.


    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 in Healthcare systems.


    This episode features a conversation with Chris Vilma. Chris is the CEO of Health Care perspectives and a senior adviser to mostly Medicaid Chris and I covered a wide range of topics which makes sense. I’ve known Chris for several years and then we have a deep well to pull from in terms of our shared understanding of the Medicaid space. Chris is knowledge on it systems and how they impact care delivery of the state and local level is unsurpassed in my experience in this industry. I’ll look Chris give his full bio when we get into the conversation.


    So here’s a few Car lights he has over 19 years experience in Behavioral Health Information Technology and health policy. He’s LED major State system transformation efforts including planning for Medicaid transformation development of a new behavioral health treatment standards service definitions and leading large information technology system implementations. He’s worked with State and County Health Department’s Managed Care organizations Community Mental Health Providers Behavioral Health County boards, fqhcs safety net hospitals and large hail.


    Systems to enact meaningful initiatives Chris was also the very first Chief Information officer for the Alabama Department of Mental Health to give you an idea of the types of things you’re going to hear about. I want to give you some highlights from our conversation. We talked about thinking about interoperability more broadly and Beyond just technology and what that may mean for making different HHS programs more interoperable.


    We also talked about how policy changes so far have been the drivers in our efforts we Had some good ideas, I think on prioritizing Frontline care Delivery Systems for interoperability first. He also talks about how my de impacted the push for interoperability. He also gives gives I think a really important look back about how hies and that experience impacted the industry’s understanding of what actually can be done when systems are interoperable.


    Chris makes some good points about how Legacy vendors are have old ways of thinking sometimes that hinders interoperability. And finally there’s a pretty important part of this discussion where we talked about how state agencies were the conduit for provider adoption incentives in the past and how state agencies need to think about their role in the next round of interoperability efforts.


    So sit back grab a cup of coffee and let’s listen to the conversation between Chris Vilma and myself about interoperability and Healthcare.


    Hi everyone. Thanks for joining us for another episode in our podcast series all about interoperability. And today we’ve got with us Chris filma who’s done a lot of things in the space and has some some very important insights and opinions to bring for the audience. So Chris, if you don’t mind kind of give, you know a few minute overview of where you know your background where you’re coming from on the topic of interoperability.


    Sure. Thanks Clay and I appreciate the opportunity. My name is Chris Velma. I am the owner and CEO of healthcare perspective have also done a number of projects with with mostly Medicaid primarily in the behavioral health and health it space prior to getting into Consulting about five six years ago. I worked in healthcare it and state government. I was the first CIO for the Alabama Department of Mental Health and implemented a number of large it system projects including electronic.


    as well as As well as Managed Care organizations and it vendors who are interested in interoperability as well. So I feel like I have a good grounding in this topic and have some expertise to bring thank you.


    So and I think if you know, my gears are turning and this this topic of interoperability, I think a lot of times gets it for based on some of the other discussions that I’ve had for this series we are Don’t want to lose sight of it’s not just interoperability even just in a technical sense. Like it’s sometimes across programs menu mention Juvenile Justice and other programs that we don’t even necessarily think of as put together with a healthcare delivery system, but I think that’s come up time. And again in these things is not just how two different systems within say the Medicaid agency work but also across sister agencies, and it sounds like you’ve done done a good bit along.


    Lawns yeah, okay. So how do you the first question we’ve been asking is kind of set the stage in the in the service of defining our terms have the you define interoperability and just sort of simple laypersons terms.


    So I look at interoperability as the ability to provide care in a full knowledge environment where you have the information flowing from every care delivery point in the system to a single source of Truth and then have visibility on that that single source of truth that all of the points of care.


    So to me perfect interoperability is perfect access to information across the various aspects of the Care delivery system, so you I think the You just described it. It’s I don’t want to say it’s unconcerned but it’s less concerned with the means of getting there and more about the outcome you I think you called it a full knowledge environment something like that. So it’s more along the lines of having that access a goal based definition of interoperability versus a features functions details specifications. Is that is that fair to describe your answer? Yeah. Yeah.


    I think that’s fair certainly the the technical specifications and the means of getting their sixth Really important to make it happen. But to me it’s interoperability is really about access and how people are able to get to the information that they need when they need it at the time and you just so one. Another question that has been pretty helpful. Especially folks like yourself who have been doing this for a while. Is this one about how long do you think we’ve been trying to achieve interoperability?


    I know personally I’ve been involved in this for Going on 20 years out of town which angle you look at it being on data standards groups way back in my Hopkins days. Yeah, but I know a lot has changed as the technology has changed. But so how long do you think it’s a multi-part question? So how long do you think we’ve been trying to achieve this thing called interoperability? And once you kind of lay out the history of that what’s different now, you know, what do you think has changed? What have we been stuck on what we’ve been trying to fix?


    You know, what are the fundamental challenges of this from your perspective? So that several questions, but if you’ll start out with the history the how long would that would be good? Yeah. Yeah, so and I actually have a little bit of evidence for this one. So I would actually put it right at 30 years and maybe a slightly longer and evidence I have for that was that when I first became the Chief Information officer for the Alabama Department of Mental Health.


    I found a report on the on the Shelf in the office that I had taken over so Took over for a long time director of it have been there for a very long time decades himself and on his shelf was a report that have been drafted in the late 80s that involve trying to bring together. The various data sources around justice-involved kids from across the state government though, even then when they had very minimal capabilities, they were trying to figure out a way to do that and it was a funded Grant under one of the federal agencies for the state to look at trying to bring those those days.


    Resources together and they weren’t successful for a lot of the same reasons. We can’t be all that successful today. They were able to do it at a one-time point. They were able to take data extract from various systems and bring them together at a point and say okay we can say at a point in time what was true, but they were not able to build anything that was interfacing or interoperable over a long period of time.


    So that was that was kind of my point of evidence or how long this has been going on, but I had an interesting report to And the challenges that they faced even in the late 80s and trying to do some of the same things that were talking about now and that would involve public health and mental health and the justice and Department of Juvenile Justice department the state court all trying to work together and had a committee and all that great stuff.


    So in terms for me what’s different obviously the technology in the speaks to that human technology changes very rapidly and the the drivers from the the system that we have now really have come much more into alignment. So one of the reasons that we couldn’t do a lot of this time for a long time was that there really weren’t the drivers there there weren’t the financial incentives there weren’t the real policy pushes to try and make this happen or the desire from a lot of the players to make it happen. So I think that’s that’s what’s different there.


    There’s definitely, you know, the policy have the new has changed the technology has Use the capabilities of changed and the desire of the players I think has changed in some fundamental ways. And so what we’ve been stuck on it is still being very held up by some dumb old ways of thinking from technology companies that the sharing information as not advantageous to their business. I want you to say old ways of thinking there may be there are real reasons. They’re there are real challenges.


    They are about how much information to share when and and having business models that are based on proprietary data and proprietary structures of things and I think there has been substantial erosion in that over the years, but they’re still that belief and still that Challenge from from companies that have built their business models particularly those that have built their business models on proprietary Data Solutions on ways, but that they see are very unique in the market and don’t want to turn that over in any way to competitors or to those that might be better able to Advantage of it in different markets. So the the fundamentals for me are using standard protocols. So this is where I do get into you know, the more technical aspects of this. I think the fundamentals are that we need to use standard protocols there.


    We need to take advantage of the apis and fire and other standard protocols to ensure that system changes and upgrades and as technology companies are thinking about future planning and new development that we’re I keeping this idea that our operability and sharing information in mind and I’m hearing that from the vendors that were working less than and vendors that I have regular conversations with that there if they don’t have a lot of that capability now that’s in their plans and what they’re thinking about and I think that’s largely because of the policy changes that people recognize they’re going to have to do some of these things that maybe they put on the back burner to really be able to work on standard platforms and Your protocols to transmit and transfer information and become interoperable.


    So I say you’re saying you feel like as far as what’s changing the we feel like the policy changes is at least driving for those that are planning ahead realizing they’ll need to have a pivot from their current model. If we’re talking about the ones that are like the incumbent vendors, right?


    Right, right and it and I think later on we’ll probably get in when we talk about stakeholders because I I agree so, you know who wins who loses all that type of stuff because I agree a lot on the current business models based on not only sort of holding up information based on proprietary information itself, but also and I think a lot of people don’t think about this all the consulting services that go with these technology vendors that is really kind of based a lot on being able to control that information access to and we are that learn I think people think of You know certain vendors is only technology vendors, but if you look at their actual revenues, you’re talking about, you know, 50% of them are also from related Consulting that uses those systems. Okay. So let’s let’s move on a little bit and if this is a magic wand question, so and let’s put yourself in the role of State.


    CIO or c2l? Whoever would make a decision in the state about which which systems need to be made truly interoperable in your in your definition from from your earlier definition, which one should be made interoperable first. Let’s say we can’t make all 30 of them interoperable at one time which one should should play together and be fully interoperable first.


    And then after that which one will be a sort of a fast follow which the critical path are Yeah, and I think for me the critical path I follow is thinking about it from a care delivery standpoint. So I start with the the systems that are documenting their delivery and and and are critical at that point of care. So the ones that are being used at the point-of-care heard of to me the first ones that need to be brought in Under the Umbrella of some sort of interoperability structure and whether that’s you know, Care Management systems or electronic health records or you know, whatever.


    That platform is that’s being used at the point of delivery to a member or to a citizen or however you structure from a state standpoint of Managed Care standpoint planning standpoint.


    However, you look at that individual is receiving Services you want those systems that are as close to those folks as possible to be integrated first and to be brought under that interoperability structure first and then add in those those items that provide more flavor and and more information about the the types or or you know, the other relevant pieces of information I can come in. So I start with those multiple structured and the unstructured data that’s been the challenge has been thinking about unstructured data and how we try and bring some of that information together for acute outpatient and Behavioral Health primary care Specialty Care pharmacies and Labs.


    We’ve done a better job list of being able to bring those in under health Should exchange structures or other types of interoperable structures and then we’ve got all the social determinants of Health work that’s going on to try and bring some structure around that as well. So I think getting that critical client level member level patient level information into an interoperable environment first and then worrying about you know, the the kinds of you know claims data and other you know, eligibility information and those kinds of things kind of come next.


    Next to me and sort of flavor the system and then whether you bring into their social service social services or Health and Human Services data and how to bring that in it kind of comes behind that that point of care point of touch point of of dealing with an individual. So so start out with if clay member or clay patient was sitting in the ER or the counselor’s office or the pharmacy or whatever everything right there.


    That’s actually Like in that it care encounter those systems right there and need to make sure their interoperable first and then whatever the next handoff is backing up away from that encounter. Is that that factor? Yeah. Yes a lot of sense. So let’s kind of talk you no longer view again. What do you think have been you know, we’ve been trying this 20 30 years. What’s been some of the successes?


    Has some of the failures what can we learn from those if you can think of you know particular efforts or initiatives, right?


    Yeah, when I think about success those I really look at the you know, the more forward-thinking health information exchanges the regional health information hubs that were around even before the health information exchanges, and there was some head-butting when you know, things were rolled out in a way that the state was expected to kind of bring those Regional organizations along with them and some It was that that was a leverage point in that worked. Well, in other places the region stuck to their region and said we’re going to we’re going to do our thing you guys do your thing. So I think from a success standpoint. I think the health information exchanges are success point in pocket so wasn’t successful and we can talk about it as something that wasn’t successful as well on the flip side of the question, but I think in specific instances there have been, you know some some real successes around Regional information.


    Herbs around accountable care organizations that are Regional so acos that has that have stood up and been able to build a data platform or acquire data platform that works for everybody within that Accountable Care Organization. I think those are the Avenues where I’ve seen some realist success where everyone’s part of the network everyone’s part of the same platform. They’re they’re exchanging their interoperable their, you know, their system talk to each other they’re able to pass information back and forth.


    And work off the same care plan and those kinds of things are happening. They’re not happening nearly enough, but there are successes that people can look at and say hey there’s you know, there’s a model that my community is replicator. There’s a model that my steak the replicate in general the states that have been successful at it or relatively small and we’re able to go and you know, sit down with every, you know, real player in the system and say, okay we’re going to do this and you guys are going to be on board and what do we need to get you on?


    I’m bored, you know they were able to get everyone who needed to be on board in a room or a series of rooms and get that done. It’s the state for communities that are much larger that have a lot more players where they can’t even get their hands around everybody. That’s a player that makes a bit more challenging but I think there are lessons learned from those successful efforts. We can you know, we can look at you know, those that moved with me and dates and those that moved without without a mandate.


    There was movement, you know before there were policy drivers or financial drivers and there was movement after their work obviously drivers and financial drivers and I think there’s value and in comparing those and saying okay, can we can we scale some of these efforts, you know, whether they were policy driven or financial driven or not, you know in our in our setting, you know, you can find an example and say are these things that can scale are these opportunities that we can bring to our community or our state?


    Just spaced on the want to you know, can we bring it to the table? Because we have the people who want to do those without a policy driver or do we have policy and financial drivers that are making us move and that you know gives you another lover to bring people to the table. So I think regardless of where your where what position you’re coming from. I think there are models out there that you could replicate it’s just, you know are the right pieces and place are the right players in places the want to there too.


    Get it done. And then remembering that health information exchanges is not the end-all be-all.


    That’s not you know, the end of interoperability just because you have some ability to exchange admission discharge transfer data or Labs or Pharmacy that there’s always more that can become interoperable and that can create that that single record or that full knowledge for somebody who is providing care to that individual or providing some sort of service to have access to the Information that’s relevant and and true at that point. I think so. I’d like to kind of like add my thoughts about the exchanges because I think they are so much richer than people realize that are kind of only on the payer claims and then a straight of data side. And then also it’s going to hold that thought for a minute and then also this idea of how you’re breaking out.


    What movement there was sort of before-and-after financial incentives and how we look at that now because I think that that’s another kind of car. That’s another thread that came up in another one of these podcasts, but on the first one, you know, I look at and I’m much more knowledgeable about what has occurred in the hies in the last year or so that I was before and I’m Blown Away with the richness of data available, right?


    So it I had no No idea things like there probably is a very detailed clinical record of clay available in the state of Alabama are whatever, you know, depends on which state I live in totally independent of payer status, right which is which I think that’s the game changer because it’s it’s payers that bring by their nature bring policies that kind of do certain things that make information.


    To get or change it up or whatever that makes sense from their perspective as a payer but it’s not like providers, you know to the extent that they’re not also a payer like a health system, whatever they’re not creating. Hey, we’re all going to process this in this way. They’re just practicing medicine. All right or whatever care. So I think the point you make about the a Chinese is a good one.


    I almost look at them at least in The Shining examples that I’m aware of and I’m sure there are others that is not not almost look at them as a very impressive proof of concept for this whole interoperability thing, right and we’re still stuck with that challenge, which is the one that I was always stuck with even when I was in one of those large analytics vendors that it’s one thing to say. Oh, yeah, we can integrate the clinical data in the claims data. That’s so much more complicated than people realize for it to mean something right for to be actionable.


    So I think we’re still Of at that Cliff or that juncture, but I know it’s there but and then my other the other thing I want to react to where you were talking about before and after there were policies or financial incentives, you know, this came up in another podcast and it was really interesting because the other the other guests was talking about, you know back and say 2011 or whatever. This was Medicaid agencies basically found themselves as the contract vehicle distribute a bunch of cash to providers.


    Us to do things along these lines, you know for EHR adoption or whatever the different incentive programs were for this and they never really had the time or stop to sekai. What do we get out of this other than being an access to the funds and I think that’s an opportunity that maybe those in the audience listen to podcast now, they’re in a Medicaid agency or similar agency.


    You know, how can you use this upcoming policy push that Talk about now to accomplish some of your own goals other than just sort of being used for your financing mechanism abilities. Any thought on that last Point Chris. Yeah. No, I agree. That’s extremely important.


    And I think they’re there’s parallel tracks going on there with you know, that that experience of having gone through the responsibility of you know, having providers adopt ehrs and meaningful use and that whole exercise and then At the same time going through this process of the modular mmis. So, you know, once that came on the scene and became something that Medicaid agencies needed to start planning for a need to start thinking about I think that those pieces coming together of hey, we went through this experience and didn’t really understand, you know through the meaningful use process what we could have gotten out of it and now we’re in this process where we’re trying to replace our Medicaid management information system.


    With more modular systems that are potentially leverageable to other programs and other agencies that opens up opportunity to that wasn’t there before so I think there is this process that that Medicaid agencies and post within Medicaid agencies are going through of hey, we you know, we’re not just you know Medicaid were, you know, we have a lot of other, you know value here and we have a lot of potential to get value from these various partners.


    That maybe we had good relationships with or maybe we haven’t had good relationships with that.


    Hey, we’ve got a lot to offer with these systems that were potentially bringing that, you know can bring interoperability, but can also, you know reduce maybe some some burden of management or what various issues that are going on within state government that Medicaid can bring a lot of value to and and as an agent of Satan can provide opportunity, so I do think there’s that Process of having gone through ACA and all the changes that came with it and having gone through the meaningful use process and having gone through health information exchange than then coming to this idea of having to replace, you know, large a large system that potentially could you know produce some more interoperability just by sheer fact of its existence. I think there’s a lot more, you know recognition of the opportunity that’s there because of the experience of having gone through some of these other things.


    Yeah, I’m glad you brought up effectively mighta because I mean if my does not a giant push for interoperability, you know, at least within the Medicaid information system Enterprise. I don’t know what it is.


    But you know, that’s probably a good place for us to look for Lessons Learned I didn’t and I don’t want to dive into that right now because I think we still I think we’re still in the early stages of seeing truly modular, you know Medicaid Enterprise systems, but I’m glad you brought the brought that up because that’s something to kind of be on the lookout for Because it’s clearly another way of exploring and implementing interoperability.


    So let’s kind of Turn the Page a little bit and talk about providers. Then we talked about this usually from payer perspective or a program perspective or technology vendor perspective. What do you think providers think of this? Like do they actually believe this is going to change much or do they think you know, I do my thing and I’ve got my system and I’m pretty good are they resistant as that changed in recent years which and you know providers means a lot of different things. So you might want to kind of unpack that.


    It what is your thought on the provider perspective of interoperability to the extent? You know, that’s on their radar. Yeah, and I will unpack it because I’m coming from a you know, kind of a unique or different perspective and that respect. So as a consultant I’ve worked a lot at the provider level with community behavioral health federally qualified Health Centers hospitals and health systems, and they do have somewhat different, you know perspectives and thinking on things but I think they get that the opportunity that’s there.


    They get that, you know bringing together this information, you know having access to more interoperable systems that are talking to each other, you know could really drive and improve outcomes. They want access to information. They want to be able to get everything they can get and they’ve been to but they’ve been disappointed so many times by the promise of things going unfulfilled or taking a long time.


    So I think going back to your example of the health information exchanges and and everything that You’ve learned about what’s there? I think what happened with a lot with the rollout of health information exchange was the promise was made at the front end that all of this would be there and when people went in and you know got their logins and went to go try out the the health information exchange. First of all, they had the, you know, get a log in log into a separate system, you know, maybe look at what was there and the first time they went in maybe all that information wasn’t there and there wasn’t a whole lot of value and then that’s what it became.


    So then was well, you know, there’s not a lot here and this isn’t of any value to me and they walked away and never went back to it. Whereas if they took that same login, you know for years later and went in and use it. There’s there’s a wealth of information there.


    There’s a whole record there of that that person’s history regardless of payer as you were saying in the state like Alabama where you have a single Giant commercial insurer and the and a single Medicaid agency that have when they just put their data together, that’s a huge, you know record and a huge database of Raishin, but that wasn’t there on day one. It took a long time to get to that point. And so a lot of the self the salesmanship has done to Providers early on was not you know delivered on early on and so when people were looking at wasn’t there, so I think dealing with providers they really see the the ability and the opportunity that’s there for interoperability whether their system can support it is a big challenge particularly with Behavioral Health practitioners.


    They don’t have the systems that are really set up right now to be interoperable in a lot of cases. Some of them are headed down that road and thinking that they need to change the system that they’re on so they can be more interoperable and some of that’s coming from the policy drivers some of that’s coming from, you know, working in accountable care organizations or other types of environments where they’re working with the health systems, and there’s also been a push from the vendors of saying hey we can provide more to you if you get your purse.


    Is on board with this as well, so I think there’s there’s definitely belief that from the provider said interoperability would be great and they see where the outcomes could could be improved if systems were more interoperable, but the failed promise of so many efforts in the past whether they be local or state or coming from the federal government. They’re just you know, they haven’t seen it and and they’ve been promised it many times.


    So I think they’re they’re getting there and understanding that maybe this time is going To be different and that the technology has changed and that they need to go through grow with the technology when hospitals and Health Systems more so have got them and and understand their deficit has been bringing the partners into into the network or bringing the partners into their interoperability.


    So they have the wherewithal to get the system to get the platform, but they’re their deficit is being able to bring the other providers into that into that same world and Some of them have done it by trying to go out with their own electronic health record and say hey, we’ll give you you know our health record or will bring you in as users on our health record and then you’ll be on our system or care coordination platforms for certain populations. But trying to really make the network interoperable has been more of a challenge and so I think Health Systems have been more of a leader hospitals and Health Systems have been more of a leader in that role in trying to bring interoperability.


    So the communities that they serve Whereas other providers have felt like there they’ve been promised a lot from interoperability, but haven’t really seen the proof of that come to pass yet in a lot of places, right?


    So for the providers that got the Maybe not quite ready version. We need a do-over but the good news is we’re making new doctors every day. I’ll be back on ones never had the bad experience and they can come on today exactly the not beta version in something and I know there’s successes and failures in that story just like with anything. So let’s kind of get let’s go I mentioned earlier we’re going to get into this part of the conversation, but let’s get into this stakeholder question.


    And in let me let me full disclosure. Let me give my my angle, you know having worked in the technology space for quite some time and doing a good bit of Market intelligence work. Just kind of looking at I think looking at I think the health care Market in particular the Medicaid market with the somewhat.


    I don’t want to say cynical but business I I’ll say I believe there’s winners and losers in this and you know, I think some people Little guy a little gal or yeah interoperability. Let me plug into that big giant system that’s been close to me essentially and then the Giants like epic or Cerner or IBM or DXE or whoever, you know, not not too particularly cast aspersions on any of those but just the giant technology companies. It doesn’t make sense to me logically that they would truly want interoperability.


    If you were to ask say Africa Cerner what is interoperability mean and we did try to get some On this series, so maybe we’ll get some later but was not successful. But if you were to ask some of them what is interoperability mean they would probably Wayne consent. Well, let’s just get everybody on our system and then and then it’ll work great. But you know, I’m I’m so that’s kind of my disclosure of I’m cynical. I think there’s winners and losers. I think the incumbents are the biggest winners and I think that’s a big part of why all this has been slow rolled. But what’s your take on that question who’s incentivized for interoperability? Who’s not?


    from a financial perspective Yeah, I think you’re exactly right and I look at it. As you know going back to my framework and way of thinking about if we’re talking about full knowledge. I look at those players in the system that are relatively information for right now benefit the most from interoperability.


    So those who would definitely have retracts us to information be plugged into systems that they hadn’t been previously plugged into, you know, the ones that already have that access and have the bulk of the information now and are You know going to be sharing that with others who are information poor are going to be on the losing it or at least see themselves as being on the losing end.


    So I do think the Giants are starting to make some movement and for me it was seeing, you know, seeing participation on panels from epic and Cerner around around trying to transmit, you know information and trying to work on some expansion of the direct protocol and thinking about and this The Cerner in particular not so much epic social participation from Cerner on that project of trying to pass more information through the direct protocol and have more closed loop referrals. They’re piloting that now, you know, it’s going to be a big effort in 2020 to try and push that out to more people but having you know vendors come to the table and have Cerner be one of those centers. I think it’s a positive step.


    I think DXE to is thinking about you know, how to how to you know, make interoperability reality particularly as this this modular mmis rollout is happening to so I think there’s a lot of drivers and a lot of factors at play but it certainly did make sense for a long time to really, you know, Slow Roll to lock it down to try and keep as much in house as you possibly could but with the combination of the policy drivers in the payment drivers, I do think the the Giants are having to to find other ways to keep their their possession of the market and keep their clients but by not resisting interoperability, so I think they’re seeing that that that that we’re going to you know, we’re going to at least start messaging that we’re not you know, we’re not resisting and and maybe trying to find ways to leverage what we have and keep our clients and and you know keep a And of our of our core system infrastructure, and those kinds of things so I think you know again looking at protocols and thinking about data as data is data and being having it be less about the functionality and more about the information flow. I also like how close are approaching social determinants and thinking about it from the standpoint of I want the education information. I want the employment information. I want the housing information. I don’t really care. What tool you use to get there.


    I don’t really care. You know, what what you’re what you’re doing in your system to try and figure out what the what role does social determinants play and what should be addressed and how it should be addressed and how you use that in care planning. I just need that information from for me because I’m providing care to this individual and I need to know what you know, but I don’t need to know everything. You know, I just need to know, you know, those basic pieces of information. I don’t need you know, all of the analytics and all.


    things that you have that are system proprietary that maybe you know telling you what risk level to assign to that person or you know, there’s things that that there’s value that vendors can still bring to the data that can be proprietary while at the same time being interoperable and sharing during a piece of what they know or the critical elements of what they know without sharing all of the until without tearing all of the business intelligence, but they have so I think that’s where We’re going to get into those push poll is how much to share and you know, how much to be interoperable. That’s not going to include the analytics that’s not going to include the business intelligence necessarily that’s not going to include artificial intelligence necessarily, although I think that’s where you’re really going to start getting into. The rub of things is what you know, what happens with those those platforms that have significant investment in analytics and business intelligence in artificial.


    Intelligence and how much of that information are they expected to share or not? Share I think is where the next real growth is going well and that’s you know is particularly I said that just to make up an entire case say Clays whiz-bang AI widget, you know can predict, you know, based on all the conglomeration of eating up all the data available for clay clay is going to have you know some major.


    The event in seven days right right hand we can it really ethically be withheld. I mean it isn’t isn’t the result and I don’t want to go on this trip. I’m just kind of pontificating but isn’t there it’s the result of that AI investment right? It’s a resulting. Hey, this is going to happen.


    So I would think that piece of information is is the property of that company, but at the same time really, you know, are we really going to say unless you Me $100, you can’t get this data point or whatever. I mean that it’s a pretty interesting thing. I think and that’s just a made up example, but I think there’s others too. I mean, I think you’re right. I think they’ll be okay. Well, here’s here’s what we can still keep secret and what we can but what about things like CPT codes, you know, a lot of people forget the AMA owns this that’s proprietary to price and that price pretty that’s pretty key to knowing if that’s like information.


    You can’t not have Have you know the CPT and what is it? What is it nine? Nine, two one three. Well, by the way, it’s an office visit and I probably just broke copyright law just by saying but you know, there’s other examples to of these reference things. There’s I can’t ever remember if it’s red book or orange bar. Whatever Merc one of them if I’m getting it wrong forgive me somebody riding in the comments for the podcast, but you know, one of them doesn’t the how they group The therapeutic classes.


    Proprietary so some of this stuff is not just like nice to know or additional insights, but actually impacts care to know that information.


    I think that will be some of the more challenging things the things that are so clearly have been for so long like cptn am a proprietary information but becomes needed more so in this new interoperable system, I mean if you look great if you want to react as fine, but that was just kind of my thoughts on a couple of Specific examples, I don’t think they really change the the overall sort of gravity of what you’re saying. But I think there will be some specific ones. We’re have to work through before others.


    Yeah, and I think the only thing I would add to that is that you know, the importance of whoever is holding the you know, the responsibility for that or the risk whoever is going to carry the risk for that individual at that point in time. That’s you know, that may be a determining Factor about what information needs to be shared with who when you know, who’s who’s at risk if this event happens, you know who’s at risk for for that payment. You know who’s going to be paying?


    I’m through that that terrible event that we think is going to happen in seven days running who’s paying for it. And and do I share that information with that person because it benefits everybody or you know, not and and what are the incentives to mozzie though? I agree. I mean try that that’s a good a good way to start to kind of pick it apart. You know who’s going to pay for the service? Also whose liability insurance is going to hit exactly.


    Yeah that type of thing so magically we’re still Back to payers, but I guess that’s the way the world Works. Let’s let’s kind of clip through a couple more of these a couple of these questions. So let’s think about a patient perspective, you know part of and I’m I’m sure I am grossly abusing the the recent Rex. I’m not I’m not trying to be the perfect expert on that.


    We’ve got others that are doing that but part of the Part of the I think the vision and the dream and the concept of interoperability from a patient perspective is member clay ought to be able to walk up to anybody in his health care delivery system be that a hospital maybe even as Pharmacy his health plan certainly as PCP and say I want all my clinical information right now. I want all my health care information right now and you know, push the do button give it to me so on so forth, you know, there’s a lot of questions.


    That like how how meaningful is that? What form does it have to come in? You know what like reading level, you know member education all that kind of stuff. But how long do you think it is before were there before Chris patient can walk into wherever and say, you know law says you have to provide this to me easily. I would like it. How long do you think it is till we’re there. Yeah, and I think before I answer the how long question I will throw out there to the other.


    The thing that I’ve been in dialogue with a lot of people in the space about is what happens if people don’t want it, you know, I think there’s a big question out there of you know, we’re doing all of this to try and get to that place where people who want access and get it what percentage of people really want that access what percentage of people really want that information but I think you know going beyond that and answering the question how long I don’t think we’re that far off in some market.


    So there are there are some So this now where you could go into to Health System who has a robust regional health information Hub or has a robust a CEO where you could get that information where wouldn’t be a huge lift for the for them to provide you with a pretty broad spectrum review of all the data that’s available about you and the health information exchange or the Hub or whatever they have.


    We may be close to that in a lot of places but for some not a lot in a few places for someone in any Town USA were quite a bit further away. And and I’d say that the majority of people. I mean, I I always has I’m always hesitant with timelines because it was all of the stuff it’s taken longer than people expected it to and it but it happened and and the like I said, I think the problem has been over promising things when the legislation is passed or when the regulations are put out, you know, we’re going to do this and you’re going to have this and it’s like well, yeah, but not today and not tomorrow and not thing.


    Here you see how it’s going to it’s going to take some time. So I think you know, it’s setting that expectation from the outset of if we passed this regulation and we’re saying this is what we want to achieve but it’s going to take you know, seven to ten years to get there or five to seven years to get there. I think that seven-year time window to me for to get to the Tipping Point is probably realistic. I hope you get there faster.


    I certainly think a lot of places will get there faster, but I think setting or more Realistic expectations about how long some of these things can take to really change systems to really, you know, make things interoperable. That was one of the reasons I love state government was just you know frustration with either the the willingness to or the the ability to or the resources to really share information and Grand and all those roadblocks. You know, I did everything I could do to pull data at a state at an agency law.


    But and then be ready to share information with other agencies and for various reasons that that just doesn’t happen. And so I think even the policy drivers in the financial drivers being there. It’s going to take some time but it’s going to happen and I think that’s the message that we need to keep communicating is we’re putting it out there. It’s going to happen. It’s just going to take some time to get there and people need to be realistic about how long it’s going to take and then I do think it’s worth asking the question what happens when we do get there how many people are really going to want?


    At that information and what are they going to do with it? And how do you put it in a format that really means something, you know, do we come up with and I don’t remember if this came up. I don’t know and see conference or some other discussion that I had with people but I think it was at the at the onc interoperability Forum this year where we talked about the idea of a credit score, you know, do you have something like a health score that that means something to people, you know, like a credit score mean, so instead of just giving them.


    You know information. Is there something you know that that could be, you know a value around, you know, their their data and what is this data actually tell you or is there some you know again a i solution or other you know application or an app on your phone that would tell you more about what that data means than just here’s the raw data of every visit you’ve ever had every medication. You’ve ever been prescribed every lab result. You’ve ever had. You know, what what does that tell?


    Oh the average user. I don’t know I think and I’ve kind of made this point and I’m not sure if I’ve made it in this series or not, but another conversations, I think I think the vast majority of people want care that much until they need it. Right.


    So, I mean there will be some data nerds like me, you know, I walk around with all my the health information on a thing that I’m tracking for lab value or whatever, you know, I just like data but for the most part Most people want won’t care about it or ask for it until they need it and when they need it is going to be when they are, you know, trying to navigate the Healthcare System probably for a sick grout. Like my prediction has been Medicaid members in particular will be the last to really engage with this but what will happen is they’ll be some medically frail kiddo some special needs kid.


    Oh that is really really sick and the Mama’s not Not getting much needs and she’s getting the runaround from different doctors offices and say hello when I will go fax this copy of this or this or pay 17 bucks get our whatever all that stuff and somebody will find out what a man is supposed to be easy, then they’ll be a lawsuit and then you know that type of thing but to I think you make a good point about you know, not everybody’s going to want this anywhere. What do we do when we get there related to that?


    I kind of want to jump to and this we can kind of kind of use this to start to lean the plane but I think there is some person I think there’s some tension between this idea of make the information way easier to get and protect the information under HIPAA. What what are your thoughts is are those two things at odds or not.


    They are they are a night and I throw in the added element coming from a behavioral health perspective of the additional protections that are still in place for substance use data as well as mental Mental Health Data Federal level and state level there are different laws and and the requirements But all under the idea of we need to protect this information, I do think in a lot of ways.


    We need to really rethink, you know HIPAA in in the standpoint from the standpoint of the way people share information today and how much information people share about who they are and what they are and where they live and where they work and all of the things that social media has brought to bear in the internet is brought to bear where we share a lot more about ourselves now and whether we need to rethink HIPAA Sure, that that rubric of the people just don’t protect their information like like they might have and I do think there’s value in protecting us. There’s value in looking at you know, how information is shared and making sure that we’re doing it in a secure way but protecting information from the people who are responsible for providing care.


    I don’t think that was ever the purpose of hip of there’s always been provision for care coordination and and other languages HIPAA that allows for people to share information. So from an interoperability standpoint, I don’t think Hitler should be restrictive and we should make sure that there’s lays that that is that it’s clear that it’s not restrictive in terms of how the the delivery of care is done.


    I do think there needs to be protection for research there needs to be protection, you know, and how information is used and shared with anybody outside of the Care delivery system and and you know penalties for people who do That but whether you know, we open some things up till allow for better interoperability within the care delivery system. And those who are responsible for paying for her care is another question. So I think the bigger challenge is the you know, the additional protections around Behavioral Health and how we break some of those things down so that you’re getting the complete picture but the desire there’s definitely a tension there.


    There’s the desire to share and the desire to free up patient information and make sure that their delivery system has access make sure the patient themselves has access the den locking everybody else. It’s like that’s that is attention. That’s a hard thing to accomplish but I do think that’s that’s the goal. I think the goal is to make sure that the patient and their and their authorized caregivers have access to the information and that the care delivery system has access to the information but that is protected from any one who shouldn’t have access to it outside of those those Catholic.


    Thank you a great great. Great discussion great insights anything you feel like we haven’t covered that you would like to make sure we get out there for the audience now. I think we’re I think we covered the landscape pretty well. Excellent. Thank you very much. That’s Chris villemarette everyone and we look forward to kidding comments and thoughts back from this episode of the of the series. That’s it for this episode in our series on interoperability.


    Be in Health Care. Thank you for listening. Don’t forget to check out more of our great content at mostly including the issue brief and other interviews in our critical Medicaid conversation series, and don’t forget to visit enter to learn more about our sponsor until next time.

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    Episode#2: Interview with Lynda Rowe

    Listen to the Podcast

    • Guest Bio
    • Transcript

    Lynda RoweSenior Advisor, Value-Based Markets, InterSystems

    Ms. Lynda Rowe is Senior Advisor for Value-Based Markets at InterSystems, and has for two decades held senior-level positions in health information technology. She was most recently an executive in the health market at Booz Allen Hamilton, where she led a number of consulting projects for the Centers for Medicare and Medicaid and the Office of the National Coordinator within HHS. She provided leadership for quality measurement, health information technology use and adoption, health information exchange, interoperability and standards, and meaningful use engagements. She spent a number of years running the analytics department for Managed Medicaid plans in Massachusetts. She is currently vice chairman of the board of directors at Family Health Center in Worcester. Ms. Rowe continues to focus on the advancement of interoperability, technology use and adoption and government policy through various workgroups and task forces.

    Highlights from this episode

  • HIPAA and our national consent model
  • How to know progress on interoperability when we see it
  • The challenge of Health IT standards not really being standards
  • Disruption in the technology vendor space as it relates to interoperability
  • The potential of richer data in the hands of providers and patients
  • Proprietary data in an interoperable system
  • FIHR and open standards
  • Fax machines as the enemy of interoperability
  • 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. 


    Hi everyone. I’m clay Ferris to practice lead for Client Solutions and mostly 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.


    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 enjoyed 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


    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 inter slash Medicaid second. Here’s the disclaimer.


    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.


    This episode features Linda row Linda and I covered a lot of ground which makes sense. She’s one of the most extensive and broad sweeping backgrounds on this topic from all the experts we talked with I learned a lot in this discussion and Linda brings a passion and death to the topic that really Bridges the gap between technical details and the patient experience. I let her give her bio and the discussion but the highlights are Linda is a senior advisor for value-based Market Center systems. She has led the health it.


    It’s for two decades and various senior level positions prior to her work at intersystems. Linda was also an executive in the Health Market at Booz Allen Hamilton there. She led a number of projects for CMS and the office of the national coordinator within HHS and Linda’s also has been a number of years running the analytics departments for manage Medicaid plans in Massachusetts. So we cover a lot of ground I’ll give you some of the highlights just to kind of see where we’re going. We talked about HIPAA and our national consent model. Linda has some good thoughts.


    Jean how to no progress on interoperability when we see it. She also points out the challenges of Health. It standards that we have not really being standards. That’s pretty important. So I encourage you to listen to that part of the discussion particularly. She talks about disruption and Technology vendor space as it relates to interoperability. She also talks about the potential of getting Richard data in the hands of providers and patients the challenges of proprietary data and interoperable systems. She gets into some of the technical details.


    The fire and Open Standards and finally, she makes some really good points that I think are that are helpful around fax machines being the enemy of interoperability. So sit back grab a cup of coffee and listen to it on this conversation that we had with Linda row. Hi everyone. Thanks again for joining us for another episode in our podcast Series where we’re talking about interoperability and with us today. We have one of the top experts on this topic in the space.


    We’re very excited to have her we’ve got Linda row with us and she’s going to have a conversation with her thoughts on interoperability similar to what you’ve heard in the other episodes or what you will hear in the other episodes been what you’ve listened to so far. But but from her unique perspective with all the work she’s done in this space. So Linda if you don’t mind just kind of give the listeners a few minutes on who you are and what you do and your background.


    Door. Hey clay, so this is when the row I currently work for intersystems, but I want to give you some background in perspective. So I’ve been doing this work and interoperability for a long time now, you know, I’ve done it inside the walls of Health Systems, but back in around 2005.


    I had the opportunity to work for an organization called the mass ehealth collaborative in Massachusetts, and we were given Some funding to actually say, you know a few sort of implement electronic health records you create an information exchange it connect to community together what good things could you do and I led a community through that process for three years. I got to work on the New York state project to create a Statewide interoperability backbone and platform. I then went on and worked through a government contract with Booz Allen.


    I worked for the office of the national coordinator where I worked in this great program clay called The Beacon communities where 17 communities Across the Nation got funded through the office of the national coordinator to actually say, you know, if money isn’t an object or you know, if you’re sort of not in a constrained budget, what can you do with health it and interoperability to actually improve the outcomes of an entire community and there were multiple interventions that were happening in each of those 17 communities, but my role is really as As the interoperability and at the time meaningful use subject matter expert to set up help guide these communities and help them think through some of the tactics and strategies to do that. I worked for o&c on program for Meaningful use stage 2 did some training there. I spent some time looking at and sitting on him as interoperability panels. I have spent a lot of time in the industry.


    Just trying Look at this topic and understand it and have been passionate about how do we make things work better for both our Health Care system if that’s what you want to call it, but also for our patients for people like me and my mom and other people who I think are unfortunately said of at the you know, the mercy almost of the health care.


    Air system and not having access to really the information that they need and so that’s been my my journey and my passion and a lot of the regulations instead of funding we can talk about later but those certainly helped push and Propel us forward in this journey. Right? Right. Thank you. And I know we’ll get it we’ll get this will get to cover sort of some members specific perspectives as well as providers as well as technology kind of as we progress through the conversation.


    But one thing I’ve found that’s kind of important in each of these conversations is let’s set the stage with you know, a definition like a lay persons simple definition of interoperability. I keep it in mind. Our audience is going to have very technical folks for a non-technical folks. But how do you define interop sort of a working definition of interoperability?


    So for me it’s about getting the right information, you know clinical and Illustrative information to the right person or the right setting of care in a way that’s actually useful and impactful.


    So if you think about historically some of the definitions that are more tactical it had to do with you know, the standards and what standards were using, but if I can’t get no the right information to that referring physician that then actually helps Have better insight into their patients and help that patient, you know make their journey to Better Health than I think I’ve failed at being interoperable. Right? It’s very similar to another conversation which we said, you know, there’s the standards and there’s the technical specifications but really does it help impact that patient.


    That’s the real the real standard you’ve obviously Really been involved at this kind of from multiple different perspectives, you know, how as an industry as a group as an industry. How long do you think we’ve been trying to achieve interoperability, you know related to that what’s different now? What would have been the sort of things we’ve been stuck on but like from a historical perspective. Where are we in the story? I guess how long we’ve been doing it.


    What’s been the Holdups, yeah, so it depends on where you want to start the story because it back in the really really early days, you know, if you think about Hospital systems and their best of breed, you know, they were buying all these different it systems that didn’t talk to each other and they were actually using internal interoperability right to share information. So I worked on a radiology information system. I had a share that radiology data back to the main hospital information system so that the Physicians on the floor is could actually see the results, right?


    that was sort of for me and that was I hate to say this but you know the 80’s 90’s that that was happening and we’re trying to figure that out then but I think that the real inflection point right for me came probably in the early to mid-2000s when a bunch of folks started to do these Pilots, right the schnoz and other things like that where there is a little bit of funding and a little bit of interest and saying, you know, we’re really not as So are we shouldn’t be as insular and really now that we are thinking about digitizing our data and this was actually for me before meaningful use that we were thinking about getting folks on to electronic health records and digitizing their health information and being able to share that because if you think about interoperability the way we think about it today, right it has to do with digitized information and for decades we did not have that digitized information. Everything was locked up in a paper chart, you know sitting in a file cabinet or in somebody.


    The trunk of somebody’s car and until that information actually got to a place where you could share it electronically interoperability sort of didn’t jump to the Forefront. So I would say that once sort of meaningful use and the use of ehrs, you know, and with their benefits and flaws the data started to become available, right? And so where are we at in that Journey?


    The good thing is we’ve moved through meaningful use we’re now at promoting interoperability the federal government did intervene because the Horses weren’t really driving it fast enough to get us to that digitized. So once you get there, then you start to say alright, so, how are we doing and getting the information and I think you know there have been efforts. There are good National efforts that happen through you know Common well in Sequoia that have helped build some of the you know framework or the the backbone, but then there are these nodes and I think the problem now is that we still aren’t connected right?


    There are still all these Pockets of very strong interoperability that might live in a particular region or particular Health Service area, but that it’s that there’s still that sort of Disconnect. So I think we still have a ways to go in this journey, but I’m very hopeful given set of what I’ve seen of the the course of my history working in this area.


    So this next topic is sort of a if you had a magic wand kind of topic and let’s A let’s say it is in an area and a market in which is kind of Leading Edge and has had had a good bit of success. What what two systems would you pick to be fully interoperable first if you had a magic wand like what are the most critical ones?


    That’s interesting if I had a magic wand. Well, I guess there are a couple of things that structurally you’d have to figure out. The first is sort of HIPAA and our national consent model. Right and I’ve told a lot of people this that that HIPAA was built around a paper world or around the claims transactions at right it really didn’t Envision all this data sharing and so sometimes it actually precludes or creates sort of a barrier for us to think.


    More openly about interoperability. But right now I think just ubiquitous. You know, I always put the I’m a patient hat. Gee wouldn’t it be really nice if when I walked into my primary care is office that I didn’t have to fill out this paper chart thing, you know fill out the paper, you know, the clipboard right? No more clipboards because somehow somebody had at least sent me a link that said here.


    Can you fill this information or it make sure it’s up to date because I understand that they need that and then when I walk And knowing that the primary care physician of the specialist emceeing actually can get to the other information about me. I mean, I would say that sort of that in my you know, wildest dreams if that really happened and it happened consistently and it happened for every patient irrespective of where they thought care. That would be my magic wand that doesn’t start to address what I would call the other aspects of our health systems or Health Care delivery.


    No, which is the Post Acute Care and getting it into social services. But like let’s just get this care coordination foundational, you know, I walk in for my visit and you know, the fact that I had a mammogram done but it wasn’t at this Hospital actually sits in my primary care is inbox is be fabulous, right? Yeah.


    I’ve even from personal experience family members having long episodes of you know, very scary severe things happening it is It is a breath of fresh air when you walk into a provider, you’ve never been in before and magically they have all your Imaging or they have I your lab and it has to do with are you still within a certain system and how that systems doing that kind of stuff but it really is nice and I think it’s so nice because it’s not necessarily common, you know at least heretofore. So what have been like looking back, you know.


    All the different things you’ve done in this what are have been some of the successes in the end in your mind and the effort and it can be even simple things and maybe even the simpler the better particularly thinking for the non-technical listeners what it what have been some of the real some of the real progress made or maybe like an example of success and interoperability.


    So I would say that the first one in you know, for those who aren’t technical they probably still know what meaningful use is I would say digitizing electronic, you know, our electronic health records and digitizing a lot of the information that’s about patient a person a member has been foundational right? Because like I said you there is no interoperability without data to share it turns a vignette.


    and successes, you know there have been some really good communities right that have set up some amazing programs where they’ve really and again, maybe it’s within a system or its across systems when I was working in the beacons, you know, they figured out how like I was working up with the Mayo Clinic and they had figured out how to get information to school systems, right so that you’d actually know about an asthmatic student and if they had an asthma attack, School would have that information and actually be able to act on it and say yes, we know this. This child has asthma here are the things we know about them. Right? It’s like those things where that information is where you want it when you want it and a boundless, you know, it doesn’t have to sit within the walls of a particular organization. It is more about the journey that a patient is taking through time.


    So those are the kinds of things when I say Aha, this is you know, this is great progress that we’re seeing, you know, and even seeing some of the work happening between payers and providers now right where they’re breaking down some of the walls and starting to share information back and forth for the benefit of their Mutual, you know patient / member and I’m starting to see more of that which I find incredibly exciting. So some of the things that are being done through the DaVinci project, which is about sharing information between payers and provider.


    Nations using some more, you know modern versions of Standards like fire.


    So let’s kind of flip the question what have been some things that have not been successful that you thought maybe you should have that were that were kind of disappointing that it took so long or has been so intractable any examples come to mind their now again, you know, and I think this was something that you’ve probably heard before is sort of you know, our standards aren’t really standards from their sort of Frameworks and Often when you think you’re getting the information you need it’s actually missing, you know the information that you thought you’re going to get. So I think that that’s been always a great disappointment. Right? You’ve got this digitized information.


    But because Healthcare is such a cottage industry instead of everybody practices differently and every HR is a little different you just don’t get that Harmony that you’d like to see in the information that we’re trying to move and share, you know, and I can just just remember when we were first doing some of this, you know, and even now where you’ll get data and you’ll look at and you’ll say wow. This is woefully inadequate, you know, we’re missing information or information the wrong kind of information for what we expected.


    I think that’s sort of one of the barriers and I talked about this before so if you know, if you want to really see a patient’s whole information we have to think about how do we move information and give patients control and And right and allow them to share that information in a way that’s controllable yet allow it to flow to where it needs to go. Once they’ve done that. Right? Right that is that is frustrating around the standards for folks that have listened to the other episodes in this series. I mentioned that you know, 20 years ago. I was on a data standards group at Hopkins and it was just chaos.


    You had all these really really smart folks trying to figure out how do we even really set a standard? That’s that’s helpful and will deliver what we expect right? Like you’re talking about not getting what you expected even when we’re using this things. So let’s let’s put on kind of a different perspective hat and think from a provider perspective. Do you think you know based based on the interaction of the providers your knowledge of the market? Do you think that providers as a group?


    Believes it interoperability is key to improving outcomes or is there is there resistance has that changed in recent years? What is the provider take on interoperability?


    You know, I think it’s there’s a spectrum right of sort of you know adoption and sort of I don’t know. It’s skepticism or you know, maybe it’s you know fear doubt and uncertainty but when I was doing a lot of my implementation work with providers around not just implementing electronic health records, but also information sharing some of them were concerned, you know, sort of who would get to see the information. Is there a liability I would say on the other end of these in vet and and Bell can’t say the word.


    Those who vandalize sharing the information and really want to see happen and it’s like are just pushing and pushing to make it happen. And and you think about the burden right? So unfortunately, we have not made this easy for a lot of our providers to do what they need to do to get the information to where they need to it’s not built into their workflow. It’s not ubiquitous.


    It’s sort of not like I walk into the room and turn on a light switch and the light bulb comes on and everything’s happy. It’s like it’s almost a lot of work that they never ever anticipated that would happen for those who really Champion it though.


    They have started to see benefit like when I log, you know, when I’ve heard provider say when I actually pull information on a patient from you know, an Information Network and hir and I actually get a hit and I get rich – And it’s the right information. I actually can do really good things for that patient because I now know way more and have much more context. But again, I think our other problem Clay is that we just overload them with so much information. So now that we have all this digitized data, we’re almost in the opposite problem, right? There’s a lot of data there’s a lot of information but how do I make it specific and targeted for what a cardiologist would need?


    What a rheumatologist would need rather than just blasting them with all this information that may not be relevant or impactful for what they’re trying to accomplish, right? Yeah. It made me think some really good points in there. It made me think about I want to say a few years ago. We would start to see, you know, General news items that say providers now have to hire an FTE just to deal with their EHR, you know, the whole new staff load or whatever.


    I have a lot of providers have scribes. That’s it there, you know do the work of putting it into the EHR. My ophthalmologist has described it sits there and does tap tap tap, you know while she’s talking. Right? Right. And and that’s what we intended. Right? Well, I was in with a family member the other day in a very Specialist of visit with a specialist and incredible provider also could type really fast and the provider was sitting there.


    Are typed in the whole time and I you know, it’s almost like words per minute should be a new hatest metric or something but it is interesting. It’s not necessarily what certainly I’m sure some of this will see change over time.


    Like that’s probably expected by doctors that are you know, finishing, you know, Med students today probably expect that versus folks that finished up everything, you know, 20 years ago or whatever so Okay, let’s kind of move into the the vendor world of this and I I believe and I’ve kind of given my disclosure of my cynicism on some of this but you know, I believe interoperability edits and at its core involves very very large technology vendors and very very small technology vendors, you know, they need to be able to to be interoperable their systems and everything in between.


    Between and the example that I give you know, if we were to talk to some of the giant systems, you know, I think it’s only now that they are incentivized to change and maybe open up some of this more but how does that how does that work in all of this? You know, what is changing now that makes it make more business sense for you know an ethical Cerner and I have all the big ones.


    I mean though, you know we We all know kind of the giant groups there. So how does this what’s different now that makes this make more sense financially for the larger vendors. It makes total sense for a patient perspective for providers in which it’s not a burden for members, you know to have that Fuller picture, but how does it make more sense now than it has before for the larger vendors. I think that’s a tricky question. Right?


    Because what I think is that many of of the larger vendors have got to figure out how to morph their their business models right and make sort of figure out how do you continue to be successful while opening the doors and making sure that you’re interoperable, you know, and this goes this is true of any of them and I don’t think I think some of the new o&c rolls around sort of information blocking will help open those doors up, but you know, Every business has got to sort of reinvent themselves or rethink who they are and their when there are these big inflection points in time. So, you know, these new rules that are coming out I think will be a new inflection point for others for for vendors big and small to rethink. You know, what is our ecosystem. How do we all play? And how do we reinvent ourselves in this in this new market?


    And I think we’re all going to figure that out and and are trying to have our strategies but I would I’d say that open systems are ones that are interoperable and can do this in a good way or the ones that and and can make it ubiquitous right that that it’s actually it helps me do my job better if I’m a provider or even if I’m a patient or a patient advocate right? I can do my job better. Those are the ones that are going to win right, you know, the ones that continue to make it more and more difficult at some point it will preclude.


    Them from being a player in the market, right? I mean to some extent you know, this is the story we’re seeing in all Industries not just Healthcare. So I mean, this is the disruption story, right? All right, it is all about this disruption and there are a lot of big disruptors that are walking into arm into Healthcare now and saying we don’t know a lot about health care, but man we know a lot about disruption right?


    I think that when you’ve got the, you know, the Amazons and the Googles and the Microsoft stepping into this market and Saying you know, we’re going to figure this out. If you long time players can’t write and that’s something especially when you know, you look back at what happened in other Industries, right? I always think about you know you I used to go first rent, you know get you know, the plug-ins for my VCR and then I got remedies and you know now I just stream it. Well gee whatever happened a blockbuster they are gone. No, I think a lot of them are starting to look in Psych.


    I don’t want to be you know, Not part of this ecosystem. So I do I then adapt and change to be a partner in the ecosystem. Right?


    I think you’re I mean, I think we have hit as you say this inflection point and I think you know the new the new regs are probably riding a wave of other things to write their kind of probably responding as well as will create new things to respond to, you know, we’ve seen to I’m extent for the folks in the audience have been involved in my de and all the Mis stuff. This is part and parcel of all that as well, correct? Yeah, so one question in this get somewhat somewhat specific to today. It’s this idea of proprietary data. I’m interested to get different guest perspectives on this not be interested to get yours.


    There is some data that is actually the data itself is proprietary the example I give is petticoats, you know that’s owned by the AMA and that’s pretty important reference information for any, you know, Care Management or anything in the healthcare space and then another you know, some of the drug therapeutic classes are proprietary assets of I think Mark or somebody else and they’ll be other examples and those are just kind of the most discreet examples, but what will be in your view the impact of increased interoperability ability on retaining ownership of certain proprietary data. How will that work? How should we navigate that?


    Well, so ownership in terms of the you know coding systems or the licensing is one thing and again, I think as a system where probably as long as they’re they own those sort of legal rights, but the information they convey needs to be interoperable. Right? So your example of a CPT code. I still have to be able to share that for all kinds of different reasons right regardless of whether I need to sort of pay to own that.


    Library and update that library on a regular basis and maybe over time that will become obsolete too because we’ll come up with some yet new set of open standard for doing this because you know, look our standards continue to evolve and maybe as an industry as there is some convergence will see new standards emerge that are more open and not proprietary. But in the meantime sort of you still should be able to share it right?


    I mean nobody owns social determinants data, and we’re still trying to even You’re out. How do you share that? Right but to some extent that needs to be shareable and we need to figure out how to do that and create a maybe even a standard for that. Now will somebody owned that standard and make it proprietary? I hope not but let’s hope that sort of there’s some openness in how we as we evolve we think about it and create new systems and new paradigms that are more sort of accessible.


    That makes a lot of sense and I try it now now my mind is turning on and open standard for procedures and diagnose. It just seems so far it seems wonderful but it seems so far off, but it would be nice. So let’s move kind of a little bit to Patient perspective and talk about this idea.


    I’m highly oversimplifying but you know, one of the things is about information blocking and in some of the new rules and or proposed rules and you know at its core I believe the idea is Clay the patient ought to be able to go to almost any touch Point within the health care delivery system his PCP certainly his health plan the hospital maybe even Pharmacy that type of thing and say I would like to access, you know, my My full record my full health care record. I guess that’s the logical conclusion and and use case of interoperability from Member perspective. And I think we talked about this a little bit. You know, we’ve both seen kind of nice but uncommon examples of that where we see things are easily at least the providers have it but I think we’re talking about us being able to get it. How long do you think that’s before that’s a reality in you know, the majority of patient experiences.


    So I want to think about this in a segmented way to right.


    So let’s think about sort of the evolution of cell phones and cell phone use and adoption and then all of a sudden we went to, you know iPhones and Androids and apps right so that Evolution took time, but not Buddy wants to use it in that way. And if you think about our population, there are some use cases where consumer mediated exchange makes a lot of sense to me as a consumer having access how many consumers will actually take advantage of that because there are some as you know in some of our special populations that will never do that. Right? Should they be able to have access to it? Absolutely. Will they access it? That’s a different question. I think some of them would rather say, you know, hey provider, it’s really your your purview to make sure.


    Information gets to my next point of care because that’s sort of part of that care Continuum and I really shouldn’t have to I call it the data Sherpa I shouldn’t have to be your data Sherpa in this in this whole thing. But what you might find very funny and this is I’m dating myself but like 15 years ago. I was in a meeting up in Vermont and this heated fight broke out in this conference in this room.


    I was in between those that believed the huh hospitals and Health Systems believe that they owned the data it was their data and that they could decide and consumer Advocates who said wait a minute, you know, I’m the patient. This is about me and I mean they were shouting at each other and I was thinking wow, this is like a really hot topic and this was you know a while back but I think you know the way I’ve always thought about it is sort of, you know, the provider or whoever the caregiver is is creating with their sort of knowledge and expertise that have an assessment.


    That is part of their intellectual sort of property and we are creating that but they are then the stewards of that information but that information should be available to the patient. Right? My bank is my Steward, but it’s still my money. Right? Right, right.


    So so I think of it that way, but I think that for every Sort of patient consumer they have to decide. You know, how do I want my information share do I want my provider to mediate that and I’ll give consent or permission in a way. Maybe that’s what my app does right? My apps is yep.


    You can share that but I don’t need to have it all on my my phone or whatever my mobile app to see it because that’s not what I’m interested in because of who I am or my circumstances and there are people like me that you know log into six different portals just because I do want to See what the information is and I want to see if it’s accurate and I actually want to may be updated if I don’t think it’s accurate or ask questions about it. So, you know, we’re all different and it’s the question is should we the answer my mind is yes, but should we make everybody a data Sherpa? Maybe not right, right. Yeah, that’s you know, what I have said on this is for the most part.


    There’s going to be a small group of people that want to just out of the gate and as people like me data nerds. I want I want as much data as I can and certain I’m very interested in myself. And I want as much information I can have from a healthcare perspective, but that’s not going to be common and I think most people want push that button that says give me all that information until they need it right until they have a very sick child or they themselves are very sick and they are not successful.


    Not getting what they need from the healthcare system so it and they’re saying, you know things like they’re dealing with oh well have your doctor fax this over to that doctor or you know pay $12 for copies of your or whatever it is all that stuff. That’s kind of been the Legacy model and I think that’s when at some point in most people’s lives. They will want to have that easy button to push to get all that information because they will then I think a lot of it will be because maybe the system has failed them.


    So maybe if Operability is as successful as we think it will be a hope. It will be it will be less need for that button to be pushed on the member side. But you know, it’s funny because what I keep saying is if we really want to enable interoperability. We have to Everyday shut down to fax machines until they’re all and then all of a sudden people will magically figure out how to share information in a different way. That is so true. That is so true.


    That you know, that could be that could be a that could be the way we fix all this that could be knowing right practical. But if you think about you know, we’re so dependent still and think about a medical school student today who like don’t even have like, what is this fax? That’s right. What are the favorite East Side training me on how to send a fax right? That’s so true. Then that you know that maybe the simplest answer of all we need we need to push for that.


    So so still thinking about you know, I guess leavers around information, you know, the rules themselves. They it has some things around information blocking him at a high level. There’s Financial penalties and there’s what I call the shame list or a blacklist where organizations that are kind of found to be blocking information be put on this theoretical list.


    Do you think that will have a big impact either the financial penalties or this Blacklist thing or is that something you Is not not a big enforcement mechanism.


    So I think that depending on what the penalties are and how significant they are and the fact that not only their penalties but it actually would be published I think about HIPAA HIPAA the penalties for HIPAA breach used to be so marginal that like it wasn’t a big deal. But now they’re so significant that a HIPAA breach is actually a big Financial hit. I mean people, you know, there are organizations. There are cleaning up messes that are costing them, you know their organizations.


    Ian’s of dollars right over over a breach and that’s a hit to a bottom line that know, you know, CEO CFO wants to see so so my guess is depending on what those penalties look like that could be a deterrent because people certainly short up their privacy and their security their security systems. Right when the reach is the cost of a breach the shame thing.


    I’m not so sure of, you know, I know that when you show a group of providers that have how they are performing against one another Sure that that in a competitive way instead of makes them realize. Oh, I didn’t realize that that’s how I was how I was performing against my peers, but I don’t know if the large-scale shaming or you know, if your name is out maybe if your names out in the you know, Wall Street Journal New York Times maybe that will influence sort of buyer Behavior purchasing Behavior, but that takes a long time to change right if you’re highly invested in in a technology a platform.


    Turning that around and change making that changes. It’s not going to happen. You’d rather see your vendor remediate right then to leave them and maybe that’s under pressure that it’s going to create play is more pressure to remediate as opposed to I’m going to bail you out but the mean time and we talked about this previously, we’ve got some of these disruptors who say, you know, we’re not going to do that.


    We’re just going to come in and try to you know, do it a different way and that it might shake it up enough, right? Yeah, I think so. That’s some good. That’s some good some good insight there, right? So it may put buyers in a better negotiating position. And if I was one of these to your point about the disruptors, I would come in and say, you know what, we’re never going to show up on that list.


    And if we do I’ll give you back 80% of your contract that or something like that, you know, they’ll start to put things at risk so it could be It could be it could have a positive effect, but maybe not necessarily just in the direct punitive path, I guess so kind of last question on this and this is your brought up. If and this is kind of to me the letters like this obvious. I don’t know if the word is tension, but you know, an interoperability is all about making the data more available and although some you know, some friends of mine.


    Who who are all about HIPAA regs would disagree I think HIPAA is all about making the day less fat. I know it’s about protecting it and all that kind of stuff. But to me, it seems like interoperability and what most of us think of as the core mission of HIPAA are at odds with each other. And then how do you think about that? What is it? What’s your take on that?


    yeah, you know it’s interesting because you know, if you read into the o&c rule around information blocking instead of what some people sort of I hate to say it maybe hide behind HIPAA in order to not share information yet on the other hand HIPAA never said that explicitly hip is actually always said that if you have treatment payment operations if you’ve got a business associate agreement if for certain types of information your Your patient can sense you can share that information. So yeah, they’re at attention, but I think it’s an important tension. And again, I think other Industries have figured this out in tackled it banking, you know tackles this all the time, right? How do I make sure that if I am in you know South America I can get cash out of a cash machine now that doesn’t mean that it won’t get hijacked because that certainly has happened but there are protections that you can put in place.


    then that your stewards put in place on your behalf, and you actually have some control over that control those levers on how tight or loose you want those as an individual right don’t ever let me, you know use a credit card out of the country unless I physically phone call you versus the user machine learning and figure out when I’m going to travel out of the country and automatically, you know know that I can use it out of the country even though I don’t give you affirmative consent and so again, I think we have to be open about how do We think about these sort of the permission in a way that is more ubiquitous in the workflow of how a patient functions in a healthcare system not how a provider or other actor functions in the Healthcare System. Right? Right. So me signing a form at the beginning of a visit. Sometimes. It’s just not a helpful thing.


    Whereas if you had something, you know, simply you handed me a tablet and while I’m waiting it you said of tap through and you understand In a language and simplicity that makes sense to you how to do this and it perpetrates through the system, you know, the or you do it on your mobile app or whatever you did make it. It’s sort of easy for the patient to feel they have control but then make sure that the stewards of that information actually enact that control in a way that you’ve expressed it. Right, right. Yeah. I think you’re I think you’re right, isn’t it?


    An important tension it still comes back to what are we really doing in terms of helping out patient outcomes. I also think your point about you know, the way hit the has been sort of implemented certainly on in the workplace. Like I at least on the private sector is not necessarily how it’s written let alone intended. I can remember working years ago in large data Hub organizations.


    And you know, we used to call legal or the CSO the anti sales department. Okay. Anyway, this has been a really really good discussion a lot of insights.


    Is there anything before one of the thing I want to talk about because we didn’t really get to it and it is Is in the rules and that’s about fire and Open Standards. And again, I know that our standards aren’t perfect. But one of the things I actually find exciting and sort of where we at today that’s different is that we’re now using some of the sort of Open Standards and some of the technology of the internet right to try to conduct and transact Healthcare business.


    So the use of Fire and Fire resources and profiles The Argonaut project things that have actually started to Think about how do we open up and share data in a way that’s not stuck in the old mode of I have to have a sort of a physical. You know, I have to create a connection point to point right?


    I can now open it up and and firing apis are not going to solve all our problems at all use cases, but the fact that we are now moving to a place where we can actually think about, you know web services and Open Access and exposing only the information that That sort of is needed at the time. It’s needed to I think that that again it’s going to take time but I think that that’s also an important Game Changer and we see fire not just here in the US.


    We see it internationally that it’s really starting to take hold around the world in terms of a way to start thinking about, you know, creating the healthcare version of the, you know, internet economy right of that data sharing and so I didn’t mention that I think that’s an important component that sits in that role is being able to expose all kinds of different information using Fire and Fire resources, right? And I know it’s something that’s come up in a few few different the conversation. So I think probably what we’re going to want to do for the folks that are listening. We’re going to want to pull together a couple of good the most Medicaid example together a couple of good resources that we make sure we kind of link out to on each of this for everybody to kind of get smart real quick on on fire.


    Fire and the API pieces of this Linda. Thank you so much. I really appreciate you taking the time and thank you for being with us today. Yeah, thank you. Totally enjoyed a clay. Take care, and I look forward to listening to all these different podcasts that you’re recording. Excellent. Thank you. 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 including the issue.


    Reef and other interviews in our critical Medicaid conversation series and don’t forget to visit enter to learn more about our sponsor until next time. I’m clay Ferris.


    Posted on

    Episode #1: Interview with Dr. Don Rucker

    Listen to the Podcast

    • Guest Bio
    • Show notes

    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. 



    Hi everyone. I’m clay Ferris to practice lead for Client Solutions and mostly 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.


    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


    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 slash Medicaid second. Here’s the disclaimer.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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?


    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.


    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?


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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?


    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.


    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.


    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.


    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.


    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.


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


    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?


    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.


    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.


    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.


    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?


    Well, you know, I think.


    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.


    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.


    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?


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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?


    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.


    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?


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    Ver I that absolutely makes sense.


    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?


    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.


    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.


    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?


    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.


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


    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.


    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.


    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.


    The system sort of runs itself.


    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.


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


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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.


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


    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.


    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?


    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.


    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.


    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.


    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.


    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.


    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.


    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.


    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?


    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.


    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?


    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.


    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.


    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.


    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.


    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.


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


    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.


    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.


    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.


    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.


    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 including the issue brief and other interviews in our critical Medicaid conversation series, and don’t forget to visit enter to learn more about our sponsor until next time.

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    Interoperability Series Opener

    Listen to the Podcast 

    • Guest BioS
    • Show notes

    Clay FarrisClay has advised CMS administrators, state Medicaid Directors, health plan CEOs, technology COOs and a wide range of other clients in the healthcare industry.  His unique blend of management consulting, project management, policy making and analytics help deliver on-time, actionable results for a wide array of business challenges. His Weekly Medicaid Roundup is read and loved by more than 10,000 professionals in the Medicaid industry.

    His experience includes policy making at both the federal (CMS) and state levels (State of Georgia), management consulting for large organizational change initiatives, big data solution sales and implementation and cutting-edge analytics. 

    He currently leads key project components related to consultation design, Medicaid subject matter expertise and project management. He has a masters in Health Policy from the Johns Hopkins Bloomberg of School of Public Health and is also a Certified Internal Auditor.

    Lynda RoweMs. Lynda Rowe is Senior Advisor for Value-Based Markets at InterSystems, and has for two decades held senior-level positions in health information technology. She was most recently an executive in the health market at Booz Allen Hamilton, where she led a number of consulting projects for the Centers for Medicare and Medicaid and the Office of the National Coordinator within HHS. She provided leadership for quality measurement, health information technology use and adoption, health information exchange, interoperability and standards, and meaningful use engagements. She spent a number of years running the analytics department for Managed Medicaid plans in Massachusetts. She is currently vice chairman of the board of directors at Family Health Center in Worcester. Ms. Rowe continues to focus on the advancement of interoperability, technology use and adoption and government policy through various workgroups and task forces.

    Kathy DaltonKathy has worked in more than a dozen jurisdictions both as a senior government official and trusted consultant. Her primary expertise is Health and Human Services (HHS); She also has extensive experience in Criminal Justice. Current activities involve developing business intelligence and data science products and services that support the use of data analytics for management of HHS organizations and clients.Kathy’s  decades of experience with government technology and management information systems helped her to develop extensive knowledge regarding Integrated Eligibility, MMIS, HIX and SACWIS/ case management systems. . In the public sector she has included managing a budget of more than $130 million and reducing discretionary spending by 9%. As an HHS subject matter expert, she been engaged in thought leadership, product development, business development and project delivery.

    Highlights from this episode

    • We provide an overview of the series
    • Our sponsor expert discusses their vision for the healthcare space and why the supported this project
    • Kathy and Clay discuss themes from the interviews

    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. 


    Hi everyone. This is Clay Ferris. I’ve got with me Linda row and this is the part of our podcast Series where we get to talk about our sponsor and and we get to hear from them about why they not only what they do and what their vision for the spaces but why they wanted to make this work possible. So I’m very happy to introduce everybody to Linda Row from intersystems and Linda tell us if you wouldn’t mind just for our audience may not be familiar with intersystems. Tell them about what you do and in the government.


    Your space and your vision for it.


    Sure. So intersystems has been in business for well over 40 years where a 1700 employees worldwide software company that’s based in Cambridge Massachusetts our mission focuses around healthy data data that has been cleaned normalized and is ready for action, but we’ve been doing interoperability for as long as we have been in business that’s been a core part of our business and our mission.


    So it’s really important for us that people Able to get the data that they need where they need it healthy data is not just Healthcare data, but many of our clients are in healthcare. For example, Premera Blue Cross epic Mass General Hospital pregnant Women’s Hospital northwell health Providence. St. Joe’s and many many others in the government space though clay. We’ve been working with the VA which is our long-standing client, and we’ve been working with them for nearly 40 years. We work with a number of State hies.


    Actually for Medicaid, so we work with the state of Alabama together with our partner cognizant a we’ve been working with the State Medicaid agency in North Carolina through our relationship with SAS. So there are a number of places that we do this and we also work with some semi private and not-for-profit organizations like manifest MedEx, which is the largest health information Exchange in the state of California Health.


    Ethics, which is the Health information exchange based in New York and others like that. So we have this very very large Healthcare footprint both us and internationally excellent was really really a lot of things going on there. Thank you for that that overview for the folks in the audience that weren’t familiar. So the the the other question that I have in this for our sponsors are why, you know, why did intersystems choose to make this project possible?


    Well, we’re you know, we’re trying to elevate the defend the most Medicaid side. We’re trying to elevate the discussion of what we think are really really important topics and the Medicaid and Health Care space, but Linda what was sort of the thinking for why you and the intersystems team wanted to make this work possible.


    Yeah, so like I said previously we have been doing interoperability with Healthcare organizations for decades. Probably one of the longest standing companies doing that and certainly when the onc and CMS rules came out about a year ago, we follow those we track them because again, we think a lot of the core tenants and what the vision is for being.


    Unable to make data available, too.


    Patients to Providers to payers to Medicaid plans to States is really an important message. And so we just were so excited about the work that you’re doing clay through mostly Medicaid to make folks aware of the importance of interoperability. And again, one of our areas of focus and interest is State business federal government and providing those kinds of technology and solutions to those.


    markets We really appreciate you making it possible. We’ve had a good time working with you in the team on this and I want to make sure that all of the audience had knows how to learn more. So how I think we’ll put some you know ways to contact on the landing page that type of thing, but what’s the what’s your recommendation and just learn more about intersystems?


    Yeah, so first I want to say it’s been great working with you clay, and I think the podcasts that you’ve been able to record been just phenomenal. I think a lot of the audience is going to learn a tremendous amount amount about what’s going on. And what’s happening right now the best way to learn about us in addition to some very specific information will put on the landing page would be our website


    We actually have a Age repairs or health plans. So that’s a great place to go. There’s also some information about our government business and another one of our pages. So a couple of places to just get information and clearly there’s a contact us page on our website as well. But we’d love to hear from folks would be interested in learning more about us and what we do with Medicaid with mcos and generally in this space.


    Well, thank you so much. I know everyone is going to enjoy the series and you’ve got an episode in their yourself as well. That’s that’s one of the best ones in there. I appreciate you doing that and thank you again for making this work possible.


    Thank you so much. This has just been a great collaboration. So we’re really excited about getting this out there.


    So that was London Eye talking about why Linda and intersystems team chose to do the project with us, and we do appreciate that and we got to hear about their vision and what they do their vision for this space as well as what they do and up next in this last segment of this this kickoff episode. You’re going to hear Kathy Dalton and I so Kathy you can check out her bio on the landing page, but Kathy did some of the interviews and I did some of the interviews and in this piece we’re going to kind of talk about our overall thoughts as we look back having completed.


    At the session so listening to that and then you’ll be done with the with the kickoff episode and then you can listen to all the rest of them.


    For this project Kathy Dalton and I were the lead interviewers before we dive into all the different episodes. Let’s take a few minutes to share our impression from the conversations. And before we do that Kathy, if you don’t mind give the audience a quick little bit about yourself. My name is Kathy Dalton and I am the CEO of a very small Health and Human Services consulting firm called Edge Government Solutions. This is certified.


    When own business in New York state and I’ve spent many years working both as a state and local government policy maker and work my way up from, you know slave to being I worked for the first Governor Cuomo has assistant secretary for Health and Human Services. I’ve been a commissioner of Social Services. I left the public sector.


    I went back to school and got a PhD and my Dissertation was on the implementation of Medicaid Eligibility policies and then I came back to the world and I have been a consultant in I don’t know more than half the states on various Health and Human Services issues over time. So and I’m old so I’ve done everything from you know, welfare reforms before Don’t Care Act to 90/10 funding so so it’s been a wild ride, but but I tend to look.


    Because I work in Health and Human Services. I do get a unique view of how all of the federal programs affect each other and I find that really valuable. Thank you very much for doing the project had a I had a great time doing it and I think we learned a lot together. So I appreciate you doing it. Let’s talk a little bit about kind of the themes that I think that listeners will hear as they as they go through the different episodes.


    I think what was entered one of the things I’ll toss out some ideas.


    One of the things that was interesting to me is how we even talked about interoperability and how I mean there’s a very technical way right which is similar to which is focused on which is the the nature of the rules themselves, but then a lot of the conversations, I know some of the ones that I had I think someone’s you had as well talked about not just the technology but even siloed program areas that type of thing Tell me my takeaway was the technology is going to help make things more interoperable. But that we still will have challenges of making sort of programs be aligned with each other. What are your thoughts on that? I think you’re exactly right on the rule itself.


    You know, it’s ridiculous to say starting with electronic health records as a small start, but but it really does starts all and it says you No beneficiaries should get copies of the information from any care that they get and then they should also that information should be shared with any follow-up provider, right? So that’s pretty straightforward.


    But it’s the beginning of laying the groundwork for what ultimately you would want which is a 360 view of your patients and beneficiaries and that 350 view really is what’s going to move us as an industry towards identifying and addressing the social determinants of health, so That that and so when you talk with various expert you really have to be on point with them about what part of this you’re really talking about because otherwise you wind up some place entirely different from where you thought you were starting. Well, I think that’s a good point.


    I think where that became apparent in some of the conversations that I had was asking how long you know, give me the history of this effort how long we I tried to achieve If interoperability and I’ve been in the vale who you talk to. I mean, there’s some people that you know, they actually make a plausible case for you know, the early 1980s. So I think that yeah and that was really interested. There’s no I mean, I don’t want to give all the spoilers. Everybody will hear a lot of detail and everybody’s story when they work through the episode when they work through the discussions, but that it is it is important when we think about where we’re where everyone thinks about where this started couple other.


    Quick kind of stakeholder perspective things and then we’ll just move on into the discussions themselves provider resistance. That’s one thing or how providers play in all of this and then another one will tackle that one first, but another big theme I think was related to sort of winners and losers in the vendor technology space. But on that first one, what was your impression around the role of providers?


    Obviously they have to use this technology that may or may not adopt it. What did you take away from from this element of the discussion?


    I actually took had to take aways that were quite different because it was depending on on kind of who is being referred to so when you talk about providers you could talk about the administration, you know, for example, the hospital presidents and CEOs who have invested millions and millions of dollars into proprietary.


    Health record electronic health records and how this rule potentially sets them up to be sharing all that information for free and you know, the the kind of disincentives to to doing that right, but then the other is the issues that many individual providers still face trying to use an electronic health record that they really don’t understand.


    And putting information into a technology. They don’t want to be using any way and that just exacerbate that problem across the the provider field if you will and so, you know, those are when you talk about data quality in particular, that’s one of the things you come up against is that all these people who are entering information in these records are not necessarily interested in making sure it’s all right.


    They’re just trying to check the box and move on so, right So, you know, go ahead go ahead. I’m just it’s really important you talk about the educational components that have to be part of implementations part of the educational component has to be educating those providers that it really does matter. Now what information you put in there.


    Right, right. I did I completely agree that you know, it’s the whole garbage in garbage out. We can make interoperable systems, but if they’re doing nothing, but sort of transporting junk data than what good has it done. So the last one the last kind of theme and there’s a lot of things to cover but I kind of want to just make sure we give the high level view. The last thing I want to talk about is disruption because I believe and this comes out in several conversations.


    I believe that this Has the opportunity to bring innovation in the health care space these rules this whole effort towards interoperability, but it is disruptive because it is potentially very threatening to very large-scale incumbent and trench technology providers.


    You know, I am hopeful that it will be a very positive thing. Although I think we see early signs in reaction to the rule that there you know and maybe a long road there might be quite quite a fight on this front. What did that’s come up in any of your conversations or did you see that as a theme this disrupting healthcare-related interoperability?


    I did absolutely see it wasn’t described in that manner. I would say so for example in our conversation with Roger. He didn’t who talks about from a user’s perspective.


    He thinks of position eruption potential as really moving Healthcare Leaps and Bounds forward because you have you’re going to have a better methodology for communicating with patients and In patients and following patients when they need assistance and it opens the door for Telehealth and other kinds of innovations that are by definition disruptive to the existing system. So that was very positive. So I think that’s I think that’s a good kind of 50,000 foot View for the themes. I am excited for all the listeners to dive into this. We do cover a ton of ground get in.


    To a lot of different perspectives that was for the whole purpose of the project was to to unearth those perspectives. So thank you again Cathy for doing the project and with my pleasure. Thank you very much. And now we’ll without further Ado will let folks listen into these conversations.