HIStalk Interviews Micky Tripathi, National Coordinator for Health IT (Part 1)

Micky Tripathi, PhD, MPP is National Coordinator for Health Information Technology.

What has surprised you most about working for the federal government?

The extraordinary amount of work that it takes to align the federal partners, working within the federal government. I don’t think I appreciated that as much when I was on the outside, where all my interactions with ONC were with things that were externally facing. I always knew that there was a role that ONC plays in coordination of the federal partner activities, but now that I’m on the inside, I appreciate how much there is, how hard it is, and how much opportunity there is. 

More and more of them are discovering that they can do things with electronic health records. As we start to move to an ecosystem that has FHIR-based APIs, they’re starting to see the value in that, which is both a blessing and a curse. The good news is that they are seeing it, and the bad news is that they are seeing it, because keeping all of that aligned is a growing challenge.

Within HHS alone, CMS creates and consumes a lot of data, FDA is looking at real-world evidence and post-marketing surveillance, and CDC has data-driven public health activities. Is there a big table where all of HHS’s groups figure out an overall HHS data strategy?

ONC chairs the Federal Health IT Coordinating Council, which brings together all the federal partners who have health IT activities going on. The last time I looked, that was probably 30 to 40 federal agencies across the government participating. I’m trying to energize that so that it has focus on particular topic areas where we can make forward movement. That’s a place we can exercise a little bit more to get more coordination.

Some of it is just reaching out and having bilateral conversations, figuring out where there’s a connection of dots to say, wait a minute, I just heard the same thing from four different agencies. Let’s try to get them together and start to think about how we’re going to think about this together.

ONC’s initial work with Meaningful Use was focused on increasing EHR adoption, and now as a by-product, we have real-time data available to support pandemic-driven clinical, operational, and research needs. Are we just starting to realize how much information we have immediately available?

I think that’s right. We had high level, gauzy ideas about the learning healthcare system. I’m not saying that to deprecate it. You would be able to tap into different types of data in more of an ecosystem kind of approach. We never really operationalized that, or we were never really forced to operationalize that. Part of it was probably because until very recently, like the last couple of years, we were were focused on laying the foundation, with that always being a part of the goal. But now here we are with a pressing and urgent need that has really tested the system.

As we look ahead, and as you pointed out with FDA and others thinking about real-world evidence and other kinds of opportunities, that is starting to come into play. It is now more more specific. That said, we are just at the beginning of thinking about how to do that. If you look at the pandemic, for example, we made very little use of the EHR systems that are in place. We hadn’t built the ecosystem around it to tap into that information in ways that are more functional than one-way reporting for what public health needs to be able to do in a pandemic. That’s the next chapter.

We’ve seen pandemic-related technology failures, such as rarely-used contact tracing apps, failed vaccine management and scheduling systems, and reliance on paper cards to prove vaccination status. How does HHS look at the role of consumer technologies as part of public health?

In all of those areas, there is a lot of opportunity for a lot of potential, and potential and opportunity with the maturity of that kind of ecosystem. Part of the challenge, probably with all of the examples that you raised, is that if you are going to think about those from a consumer access perspective — and a couple of them arguably could be thought about that way, like contact tracing and the vaccination credentials, with scheduling being a little bit harder – you would want to leverage the maturity of patient experience. Patients are familiar with the idea that there are use cases where they have, at their fingertips, control of health data. They can interact, both in terms of getting data as well as interaction bi-directionally or in a more synchronous way than they are able to today.

We are at the very beginning of the beginning. Most people don’t realize that they can download records onto their phone, for example. Because of the way that health information technology has rolled out over the years, and because it’s new in terms of EHR penetration, for whatever reason patients don’t naturally think of apps as being the way that they can interact with healthcare, even though they do that in every other walk of life, such as Uber or ordering food or whatever, where they turn to their favorite apps. Until now, that has been an unnatural act for them. I think that will be more of a natural thing in the next few years and we’ll probably get a better reception for these kinds of capabilities.

We will also face a challenge in that we want to make the opportunity available to patients, but we still don’t have the answer of how many patients actually want to have that kind of interaction with healthcare. To me, that’s an open question. I don’t think that that undercuts at all the obligation on us as an industry to make all of that data available in the easiest possible ways possible for individuals so that they can take that opportunity where they want it. But I do think it’s still an open question of how much they patients themselves want to be in the driver’s seat for that.

We haven’t seen much evidence that supposedly empowered healthcare consumers will vote with their feet in leaving providers who don’t practice transparency or interoperability. That means the only available recourse is for a patient to recognize then their provider isn’t following the rules, then take the trouble to report them for possible government action.

There are real questions about whether healthcare will be a consumer good that conforms more to neoclassical economics and markets than not. That is a testable hypothesis that we will see. But I agree that there could be challenges there in terms of consumers wanting or being able to act in that way, because of the complex economics of healthcare and the complex ways in which people decide on their care. And how willing or able they are to break out of that to do consumer search, and thinking about healthcare as something that you do real search for based on value, cost, and quality in the same way that you do with other kinds of goods and services.

My kids certainly approach healthcare differently. They are much more willing to go out get healthcare on the spot market, as it were. Whereas when I think of my own care, I’m in a system and I’m going to stay in that system because I’m concerned about interoperability not happening. I’m voting with my feet to say, I’m going to go to a place where I know that all of my records will be in the same place. It’s multi-specialty and all the specialists are are tightly connected to a hospital in a very good hospital system. I’ve basically voted with my feet to say that I want to make sure that I’m in a system in which I know that interoperability is going to happen.

Whereas my kids are much more willing to just be in the spot market and say, I’ll just find a doctor based on some kind of scheduling app or whatever it is. I’ll go see them, and then I’ll go somewhere else. Now of course they have few needs and lightweight needs, and maybe their views will change once they get older and they have more acute needs or more ongoing needs. But we should all leave open the possibility that we’ve got a generation of digital natives who may genuinely think about this differently.

The providers in that spot market that you mentioned are likely to be in urgent care or telehealth companies that probably need the patient information that big health systems have, who in turn aren’t as interested in getting data from those spot market providers. How do you address information blocking if it is mostly big health systems that aren’t willing to share?

That’s all a part of information blocking. There is a requirement for them to share that as the first instinct, and to only have good reasons for not sharing. It is precisely designed to address that.

Going back to that expectation of a younger generation, although we don’t want to paint people with too-broad strokes, there is an expectation that interoperability is happening in the background. My kids, even if they are on those spot markets, have an expectation that their information is being shared behind the scenes, and may they have less tolerance for that information not being there. Then, through their own searches, they may discover places where that’s happening versus not happening because of efforts that are going on or not going on behind the scenes to get that information to the right place. There is certainly a regulatory angle to that, which is about information blocking, but there could be a consumer demand angle for that as well.

How do you educate consumers who perhaps have never actually seen interoperability in action that they should have those expectations and that providers who don’t share information are not complying with federal requirements?

Interoperability is happening that is invisible to patients. They expect that more of it is happening, by and large, than is actually happening, which is always eye-opening to some people. Their ability to have apps with features they are used to in other parts of their lives might be a way of being able to expose in a more direct way whether interoperability is happening.

Some of the more innovative payer systems do these kinds of things, with apps and functionality where users can track the progress of prior authorization and referral notes. Those can start to put in front of the consumer the basic kinds of customer service things that they see happen when they go to Home Depot and Amazon, but that they don’t see happen in healthcare. That can make it a more explicit what’s happening behind the scenes and can point out where some of those things aren’t happening behind the scenes. I don’t think that happens overnight and that’s fairly spotty what I just described, but it’s not hard to imagine that if you start opening that up, that starts to give more visibility and more of a window into what’s going on behind the scenes. But right now it’s all been under the covers.

Who do you expect to file information blocking complaints, consumers or other providers?

We are open to all, obviously. I find it hard to believe that a large number of patients would be coming forward with those kinds of complaints about provider-to-provider exchange, simply because they may not be aware of it. You can imagine more coming forward with complaints about their own access to their own records, which is also an important part of information blocking. The more savvy have an expectation of getting access to their own records. I can imagine more of them filing a complaint about information blocking because their records should have been transferred from the ED to their primary care physician and weren’t.

That seems like a less likely scenario to me, but again, that could change. We’ll see what happens. Because of institutional knowledge and the awareness in the industry, more of the complaints are going to come from organizations, whether it’s vendors, providers, networks, or those who are covered by them or who have an expectation of what the opportunities might be with information blocking, and then try to test it and find that it’s not there the way they perceive it should be there. I think that’s going to be more of what we see, but we’re still very early.