0:00

People say this all the time we're going to reduce the cost of care

0:02

. It's like , well , we're not really going

0:04

to reduce the cost of care , we

0:06

hope to reduce

0:08

the increase in

0:11

cost growth . We

0:14

hope to be more productive

0:16

or efficient , meaning that we are getting more

0:19

health care quality per unit dollar

0:21

that we're spending . But those aren't

0:24

obvious things . Those are not obvious

0:26

things to measure , particularly when

0:28

health care quality has got

0:31

many , many , many non-monetary

0:33

aspects . What is the value of

0:36

an improvement in my quality

0:38

of life so that I have

0:41

managed diabetes , for example

0:43

, or I don't have my leg amputated or

0:45

any of those things that are about my quality

0:47

of life ? How do we actually measure that in

0:49

a way that enters that value proposition equation

0:52

in the same way that it does when I purchase

0:54

a computer or a TV , where

0:57

you can have that price quality chart and

0:59

it's pretty easy to make those estimates

1:02

of demand , supply and what additional value

1:04

you get for that next

1:06

increment in capability in my TV or

1:08

my computer ?

1:09

Welcome back to the Chilcast , a

1:11

health care podcast from Chilmark Research

1:14

, helping health care leaders make

1:16

the best decisions for the populations

1:18

they serve . Welcome

1:25

back to the Chilcast . I'm the managing

1:27

partner of Chilmark Research and your host today

1:29

, John Moore III . This is the fifth

1:32

episode of our mini series delving

1:34

into how thought leaders representing different

1:36

industry stakeholders think about assessing

1:38

the value of digital health and health IT implementations

1:41

. So we appreciate everybody that has

1:43

been tuning in and welcome to

1:45

our new listeners . This

1:47

series came about as part of a new collaborative

1:49

effort , the Health Impact Project that

1:52

Schillmark convened earlier this year with Curtis Peterson

1:54

of King Fisher Advising Marie Coppola

1:57

of Horta Health , and Pam Arlotto and Susan

1:59

Irby from MyEster Strategies . After

2:02

hearing ad nauseam over the last couple of years

2:04

how important it is for new technologies to

2:06

show efficacy in the current economic climate

2:08

, we decided that it was time to come up with

2:10

a better metric for evaluating the impact

2:12

of technology than a standard , oversimplified

2:15

financial calculation like ROI . This

2:18

series is intended to catalyze industry

2:20

conversations that we see as necessary

2:22

to reach consensus on a new model of value

2:24

that C-Suite's care organizations

2:27

, payers , technology developers , investment

2:30

firms and more can apply to their own initiatives

2:32

. So please be sure to follow

2:34

us on LinkedIn , via the Health Impact Project

2:36

page , for updates and new contact

2:38

, and be sure to subscribe to this podcast

2:41

to not miss any episodes as

2:43

they are released . So

2:45

for our fifth installment , I am pleased to introduce

2:47

none other than Micky Tripathi , PhD

2:50

, current national coordinator of health information

2:52

technology at HHS , where

2:54

he leads the formulation of

2:57

federal health IT strategy and coordinates

2:59

federal health IT policies , standards

3:01

, programs and investments . This

3:03

makes him arguably the most influential public

3:06

servant in our healthcare IT space

3:08

.

3:08

Hi , john , really glad to be here .

3:11

It's our pleasure , really looking forward to this conversation

3:13

. So , for those of you not

3:16

already familiar with Mickey , he is one of those industry

3:18

heavyweights that generally needs no introduction

3:20

, but it's definitely important to provide a

3:22

brief history of his career as valuable context

3:24

for what we'll be discussing today . Dr

3:27

Tripathi brought over 20 years of

3:29

experience across the healthcare IT landscape

3:31

to this federal appointment . He

3:33

most recently served as chief alliance

3:35

officer for Arcadiaio , a

3:38

healthcare data and software company focused

3:40

on population health management and value-based care

3:42

. He was the project

3:45

manager of the Argonaut project , an industry

3:47

collaboration to accelerate the adoption of

3:49

FIRE , and a board member of HL7

3:52

, the Sequoia project , the Commonwealth

3:54

Health Alliance and the Caron Alliance . So

3:56

all very interoperability , heavy initiatives

3:59

and standards-based bodies . Mickey

4:01

served as the president and CEO

4:04

of the Mass E Health Collaborative , a

4:06

non-profit health IT advisory and clinical

4:08

data analytics company . He was

4:10

also the founding president and CEO

4:12

of the Indiana Health Information Exchange

4:14

, a statewide HIE partnered

4:17

with the Regan Streef Institute , and

4:20

he's also an executive advisor to investment

4:22

from LRV Health , who we actually

4:24

spoke with on our last episode , and

4:27

a fellow at the Berkman Klein Center for

4:29

Internet and Society at Harvard University

4:31

. These were all roles that he had

4:34

before coming to the Fed , which is now his

4:36

only current role . He

4:38

holds a PhD in political science

4:40

from the Massachusetts Institute of

4:42

Technology , a master of public

4:44

policy from Harvard and an AB

4:47

in political science from Vassar College , which also

4:49

happens to be my alma mater . So go

4:51

Brewers , not that sports are a

4:53

really big thing there . Prior to receiving

4:56

his PhD , he was a Presidential Management

4:58

Fellow and Senior Operations Research Analyst

5:00

in the Office of the Secretary of Defense in Washington

5:02

DC , for which he received the

5:04

Secretary of Defense Meritorious Civilian

5:07

Service Medal . So

5:09

yeah , really excited to kind of go deep

5:11

into Mickey's career

5:13

and what he sees the

5:16

role of the federal , you know

5:18

, regulation and involvement with health care , it , adoption

5:20

, going forward .

5:22

Great .

5:24

So let's start with kind of

5:26

your earliest days . You got into

5:28

health care IT after you received

5:30

your PhD in political science , so

5:32

that seems like a pretty non-traditional path , but

5:34

I feel like that's how a lot of us end up

5:36

in health IT . It's not necessarily where we intended

5:38

to start or end up in , but

5:41

would you mind sharing your story how

5:43

you went for PhD in polypsi

5:45

and then , you know , ended up being as influential

5:47

and kind of the interoperability in health care IT world

5:49

.

5:50

It is definitely non-traditional , but

5:52

I guess I've always been , you know

5:55

, sort of very intrigued by and interested

5:58

in areas that kind of bring together

6:00

technology , technology

6:02

slash science , policy

6:04

and business . It

6:07

wasn't a deliberate strategy , it's just like looking

6:09

back . It's where I sort of see that I've , you

6:11

know , sort of found myself . I worked in the defense

6:13

industry , in the Pentagon , for a number of years

6:15

and

6:18

found myself sort of in the middle of that

6:20

, you know , right at that nexus as well , you know sort

6:22

of thinking about the

6:24

economics of weapons

6:26

procurement , well , real asset management

6:28

and weapons procurement and policy and

6:31

you know sort of science and technology piece of

6:33

that . So in some ways was

6:35

, you know kind of you know very similar

6:37

to where I ended up in health , it and

6:40

my in studying political science

6:42

. I was very focused on . I

6:44

mean , I started off pre-med in college and then in

6:47

studying political science I was much

6:50

more oriented toward the economics

6:52

and quantitative

6:54

methods side of the house . So

6:57

I was in the political science program at MIT

6:59

but I did the doctoral requirements for

7:01

the economics degree as well and

7:04

taught statistics . So I was always

7:06

like a weird , you know sort of more

7:09

technically , quantitatively oriented

7:11

type . And then

7:13

once I thought that I was

7:15

going to go teach , but then , as

7:17

I sort of looked at what teaching jobs might be like , realized

7:20

that that was really not going to work out . I already had

7:22

three kids at that point . I got my PhD

7:24

a little bit later in my career . I

7:26

already had three kids , was

7:28

unwilling to move from Boston and so

7:30

had to look , you know , for other opportunities

7:33

. And

7:35

right around that time this was like the late

7:37

90s , early 2000 , like late 90s the sort of the dot-com era was really

7:39

peaking and the management

7:43

consulting firms in particular were

7:47

recruiting very heavily , particularly outside of the

7:49

MBA cohort , which is where they typically went

7:52

. They were starting to look at MDs , jds and PhDs . And

7:55

I got caught up in that

7:57

, got very interested in the

7:59

Boston Consulting Group as one

8:01

firm and that's where I ended up . So

8:04

I was there for like five or six years and

8:08

that's where I got really interested in sort of getting my hands really

8:11

dirty and sort of the business elements

8:13

or the business drivers of value . But

8:16

even there was gravitating toward the areas that

8:18

had a significant public policy dimension

8:20

. So

8:22

one of the last engagements I had

8:24

was working out in Indianapolis founding the Indian

8:26

Health Information Exchange and that's

8:28

what really got me sort of involved in Health IT and

8:34

when I decided that this was

8:36

kind of the industry that I wanted to focus on .

8:40

Okay , I know that's fantastic context , especially

8:42

given that the purpose of these conversations

8:44

that we're having are to think about

8:46

kind of the economic impact , the role that

8:48

healthcare technology and data

8:50

technologies coming into healthcare can have

8:53

on truly unlocking

8:56

new value drivers in the

8:58

healthcare sector . Because , as you know

9:01

first hand , inefficiency

9:03

and administrative

9:05

ways are two of the biggest drivers of kind

9:07

of unnecessary expenses in the healthcare space

9:09

, and technology is primed to

9:12

help with those specific problems

9:14

. So , with that

9:16

context and the purpose of this endeavor

9:18

to be developing a new model for

9:20

assessing the value that technology

9:22

delivers in any healthcare

9:25

context , any use case you

9:27

know that these are very broadly

9:29

differentiated use cases and

9:31

that is no easy task . So

9:33

, given your economics

9:36

background and understanding

9:38

the public health aspect of policy

9:40

, how do you think about

9:42

defining the value

9:44

of technology ? How do you think about ensuring

9:46

that what people

9:48

are focusing on and what you can drive people

9:50

to focus on in your role , is actually going to

9:53

have a substantive value

9:56

, impact and outcome for people

9:58

that are deploying these new technologies ?

10:02

Yeah , I mean , I think you know we've

10:05

got a significant challenge in

10:07

healthcare in the US which

10:09

is just the fragmentation of

10:11

, you know , of our healthcare system , and I'll

10:13

put system in quotes . And

10:16

you know , in a country as

10:18

big as ours and as fragmented

10:21

as ours On almost every dimension

10:23

you can think of , and certainly you know , healthcare

10:26

is , you know , is

10:29

, you know , probably the biggest example

10:31

of that , if not one of the biggest examples of that . The

10:34

challenge that we have with almost anything

10:36

is you know what in political science and economics

10:38

they call a collective action problem , which

10:40

is how do you get an industry to move forward

10:43

in a more

10:45

, you know , in somewhat of a synchronized way when

10:48

it's very , very fragmented ? And

10:51

you know it's not as if you can just get , you

10:53

know , seven or eight large companies in the room

10:55

, like you can with banks or like

10:57

with airlines , and get

10:59

an industry agreement among them

11:01

. Usually they themselves , you

11:03

know , are part of driving . Because

11:06

they can , you know the industry side , they're able

11:08

to solve a collective action problem themselves

11:10

or with , you know , relatively little help from

11:12

the federal government . In healthcare we don't have

11:14

that . I mean , if you look at you know

11:16

, we have large provider organizations

11:18

that are nationwide , but

11:21

in most cases they're small in

11:24

most markets . Yes , united

11:26

Health Group is very big in Massachusetts they're

11:28

not really a driver of . You know what happens in the Massachusetts market

11:31

and

11:36

you know the same thing for Ascension Health you know

11:38

very big national integrated delivery network Don't really

11:40

drive a whole lot in , you know , in

11:42

many , many markets , indeed most of the markets in

11:44

the country . So

11:48

you've got this . You know this anomaly that we have

11:50

some very big organizations . Some of them

11:52

are nationwide organizations or maybe it's

11:54

best to think of as multi-regional organizations . And

11:58

the challenge that we have in healthcare is , you know

12:00

, how do you get coordination

12:03

to have the industry drive forward , particularly

12:06

in areas of technology that can

12:08

help to drive the kinds of efficiencies , the kind of higher value

12:10

that we've seen in other industries ? And

12:14

in the absence of market type of orchestration

12:17

you need , I would argue , you

12:19

know , in the healthcare industry you need the

12:21

federal government to be able to play

12:23

a role in kind of tying it together , providing some of that systemness that

12:25

we don't have and

12:29

I think that that's partly , you

12:31

know , sort of owing to the federal government's presence

12:33

in almost every market . So

12:37

you know , it may be that United Health Group

12:39

isn't big in every market , but Medicare and Medicaid sure are Every

12:41

single market you can think of . There are providers

12:43

who are a part of Medicaid , you know , serving

12:45

members of Medicare and Medicaid

12:47

. So it's one aspect , just the participation that only the federal

12:50

government participates in almost

12:52

every market that you can think of across the

12:54

country . The

13:00

second is just that regulatory dimension , that the

13:02

ability to judiciously

13:04

apply regulation that helps the market

13:06

itself move forward and overcome

13:08

some of these collective action problems I think is

13:10

a critical role of the federal government .

13:13

Okay . So getting back to the value piece

13:16

, how do you think about the government

13:18

actually like defining

13:21

the value that people should expect from the

13:23

various initiatives that you're trying to drive

13:25

forward ? So you know , interoperability it's

13:27

almost impossible to assign a specific ROI

13:29

to having data flow . So how do you think

13:31

about value when you

13:33

are not thinking necessarily about dollar and cent

13:36

?

13:36

Yeah , I mean , I think you know , for some of this

13:38

there was , you know there was a lot of effort over

13:40

a number of years to define

13:43

the ROI you know for

13:45

interoperability . There were a lot

13:47

of studies going back to it was an organization

13:49

called CITL , the Center

13:51

for Information Technology . I even have

13:55

their study here on my bookshelf

13:57

. That like like tried to do a very

13:59

specific value proposition

14:01

dissection of what's the value proposition for payers ? what's

14:03

the value proposition for payers large providers , small

14:06

providers what's the value proposition ? And try to sort of

14:08

craft it as almost like a business strategy

14:10

and to see if they could thread the needle

14:12

you know to have . you

14:14

know that sort of be this epiphany

14:16

for all those stakeholders of ah , there

14:18

it is . Now I will , you

14:21

know , sort of , you know , make the investments

14:23

. Because I see the ROI and

14:25

I think after a while a number

14:27

of us just threw up our hands and said

14:29

that the health care is

14:31

too fragmented and the economics

14:34

are too opaque for

14:36

us to be able to , you know , really , you

14:38

know kind of drive it in that way and

14:40

so we really have to , you know , sort of go

14:43

on the assumption which I think is a very

14:45

, very good assumption that interoperability

14:47

is good . It is good and

14:50

it will deliver an enormous number of benefits

14:53

on a lot of different dimensions , and

14:55

it is a public good in

14:57

the economic sense . So the economic definition

14:59

of public good is something that benefits society but

15:01

that no actor finds

15:04

it in their rational self-interest to make the investment right , the

15:07

tragedy of the commons , the whole thing right . I

15:09

mean , all of that is just different elements

15:11

of a public good story . Interoperability

15:13

, I think , falls into that category . Even before that

15:15

, electronic health records fell into that category , people

15:18

weren't willing to invest in electronic health records

15:20

, which is why we had industry stalemate for a number

15:22

of years , and it wasn't until

15:25

Medicare

15:27

and Medicaid essentially through high tech as

15:30

the only players across the country

15:32

who had an interest

15:35

in all markets to

15:37

invest in their supply chain that it

15:39

basically broke the prisoner's dilemma , you

15:42

know , or the public goods problem . However you want to sort of think

15:44

about that they were able to break

15:46

that stalemate to say , well , we

15:48

, the federal government , can invest in that

15:50

supply chain for our business purposes

15:53

, which is Medicare and Medicaid , but that will

15:55

also have spillover effects to the entire economy

15:57

. And so being able to sort of break that open

15:59

, first for electronic health records

16:01

and then for interoperability , is kind of I think

16:03

you know more of the approach that we're taking . And

16:06

you know , and I think you see it in the 21st Century Cores

16:08

Act , which basically said you

16:10

know , interoperability is the natural state

16:12

, which is essentially what that said . You know

16:14

, the whole idea of information blocking is that

16:16

information should just be flowing . That's

16:19

. You know , that's the way it was intended , you

16:22

know , but from by whatever higher being

16:25

you think defines these things , that

16:28

data and healthcare data should just

16:30

be natural flowing , and the idea of information

16:32

blocking is that you need to have

16:34

a very good reason to interfere

16:37

with or prevent that information

16:39

from flowing . And they weren't

16:41

. You know , they weren't thinking about oh , I need an ROI

16:43

calculation at that point . It was just

16:45

that you know , value will

16:47

come to everyone through information

16:50

flowing and for those who

16:52

feel that it

16:54

upsets their markets . Those are

16:57

organizations who are basically

16:59

making profits on the inefficient side and

17:02

obviously , as a federal government , we're , you know

17:04

, going to try to prevent that .

17:07

Yeah , inefficiencies or potentially

17:09

anti competitive behaviors that they don't want exposed

17:11

Obviously .

17:15

No different than any other industry I

17:17

think that's something we always have to remember is

17:19

it's it's a business in the US

17:21

. It's a business . It's a business . We'd

17:24

like to think that certain aspects of it are

17:26

a higher calling and you know , my parents are doctors

17:28

, my daughter's doctor . There is a higher calling

17:30

there , for sure , but the

17:33

basic drivers of you know , of

17:35

the , of you know sort of the industry

17:37

are business drivers and we just have to

17:39

remember they're gonna act like other

17:42

businesses , act in many , many ways , not

17:44

not always , but many , many ways .

17:45

So when we think about the

17:48

hard kind of value of

17:50

interoperability and that being a bit Difficult

17:53

to define very specifically the

17:55

government's kind of way around , that is , to your

17:57

point , the info blocking rules . So

17:59

I've looked at the info blocking Disincentives

18:02

that you guys published this year , so congratulations

18:04

on getting that final rule out there . But

18:06

I think for a lot of people the

18:09

way that it's worded like with a lot

18:11

of federal Legislation , a lot of

18:13

rules it's worded in ways that can be

18:15

a little bit difficult for a layperson

18:17

or for somebody that's not on the legal side to understand

18:20

. So could you give us a concrete example

18:22

of what the penalties

18:25

, the disincentives , would actually look like ? Edit , you

18:27

know an organization of some specific

18:29

side , sure ?

18:30

And so the first set

18:32

I should you know , we should be clear

18:35

and this was in , you know , secretary

18:37

, by Zara step statement with the release

18:39

of the of the property disincentives

18:41

, as it was called , draft

18:43

rule was that this

18:45

sets up a framework For

18:48

this initial set of disincentives

18:50

, with the anticipation that there will

18:52

probably be more that fit within to this

18:54

framework . So the first was establishing how are we going

18:56

to approach this from a general regulatory

18:58

policy perspective , and establishing that

19:01

first and then saying here are the first

19:03

set of you know of

19:05

, of appropriate disincentives . So the three

19:07

that are proposed right now are in

19:09

, are in the CMS program . Again

19:12

, there's nothing that limits the appropriate disincentives

19:14

Program from being limited to CMS

19:16

. That could really be any agency in the Department

19:18

of Health Services and as the biggest

19:21

grant-giving organization in the world , there

19:24

are many , many agencies that that

19:26

do have programs that

19:28

you know that that Organizations

19:30

do receive funding for . So

19:33

but you know , the first set of disincentives you know

19:35

comes through the CMS program and

19:37

it it looks at our

19:39

focuses on three . You

19:41

know , three different types of actors . So in

19:44

information blocking there's the idea of actors

19:46

who is responsible for not

19:48

information blocking , and there are three

19:50

name types providers , health

19:53

information networks and Certified

19:56

technology developers , which would be , like you

19:58

know , electronic health record vendors . So those

20:00

are the three actors who are named , and

20:03

so in identifying , electing a

20:05

set of appropriate disincentives , you first have to ask yourself

20:07

well , where are there government

20:09

programs that actually Involved

20:12

in some way those particular types

20:14

of actors ? And of course , you know , once you get to providers

20:16

You're talking about , you open that box

20:18

up and then it's like , well , there's hospitals

20:21

and there's physician offices , and there's

20:23

federally qualified health centers and there's LT

20:25

pack and there's behavioral health and right

20:27

and so , and each of those has

20:30

different programs associated with them , right

20:32

in different agencies . Samhsa works with you know , something's

20:35

used providers , and HRSA works with federal

20:37

health centers and CMS works kind

20:39

of with all of them . And yeah , so anyway

20:41

. So that's kind of the you know sort of the more detailed

20:44

work you have to do is say , well , each

20:46

actor in theory needs

20:48

a penalty associated with them , and

20:50

so how do you work your way through that ? So the first

20:53

, you know , the first set of appropriate disincentive

20:55

proposals are focused on three

20:57

general types of actors . One is

20:59

hospitals , emu

21:01

eligible providers second category , which is basically

21:04

a physician offices or physicians working in an

21:06

ambulatory setting . And then the third would

21:08

be accountable care organizations and , and

21:10

, and the first two , without

21:12

going you know deep , deep , deep into the weeds on it

21:15

, are essentially a proposed

21:17

appropriate disincentives which would

21:19

, you know , sort

21:21

of limit the , the

21:24

score that they can get for

21:26

certain CMS Incentive

21:29

programs , so promoting interoperability

21:31

, for example , or the MIPS program that you

21:33

know that maybe mumbo jumbo to lay

21:35

people , but Physician offices and

21:37

hospitals absolutely know what those programs

21:40

are . And those programs are programs

21:42

where they can get incentive

21:44

dollars for using , you

21:47

know , electronic health records in certain ways

21:49

that will benefit interoperability . And

21:51

so there's a you know sort of a straightforward

21:54

scoring mechanism they

21:56

get for doing different things and For

21:58

the physician offices in hospitals . That basically would

22:00

say , if you were found on

22:03

investigation by the office of inspector

22:05

general , to be an

22:07

information blocker , as it were . That

22:10

CMS would then have the

22:12

the ability to essentially for

22:15

one part of your score , which is about interoperability

22:17

, I think are using health information exchange

22:19

, or I think it's that categories Would

22:22

essentially say that you get a zero

22:24

score in that category , and

22:26

so at the end of the year , once you're going to rank all that

22:28

up , you know your total score , or then

22:30

calibrates to how much incentive payment do

22:32

you get . So essentially , we'll put a cap on

22:34

you know on how much incentive

22:37

payment you would get , so you know

22:39

the estimates . When we provide this in a rule might be

22:41

, you know , and it depends on you know the

22:43

size of the organization . So it could be like

22:46

for an individual provider , it could be something

22:48

like if you're just a solo practitioner on

22:50

the very low end , that might amount

22:52

to less than a thousand dollar penalty , which

22:55

is really not a penalty per se , it's

22:57

money that you could have

23:00

gotten that as incentive , but you're not getting right

23:02

. But it could amount to

23:04

like for a hospital or a large physician practice

23:06

it could amount to something that's in a hundreds of thousands

23:08

of dollars . So you

23:11

know , kind of read it varies . I mean

23:13

that way for the ACO's the

23:15

proposed penalties a little bit different . It

23:17

would actually preclude an ACO

23:20

organization from participating in

23:22

the program for up to a year . Is

23:24

the proposal , which again is , you know , pretty

23:26

significant Penalty . I mean , if you're an ACO , you

23:29

know , in in an MSSP ACO

23:31

, for example at CMS , you know that's that's a big

23:34

deal for sure . But but

23:36

I think you're supposed to have bite right , I mean there's . So

23:40

anyway , you know there are many , many more

23:42

details , but hopefully that gives a sense just broadly

23:44

of you know how those opposed incentives

23:47

work . And again , this is a draft rule . So you

23:49

know we welcome comments or you know we're

23:51

it's a department rule , it's not no one see rule . We

23:54

were asked by the secretary's office to just

23:56

basically have the pen because it involves

23:58

multiple different agencies . But

24:00

you know we look forward to , you know , to people's

24:03

feedback and comments .

24:05

So do you think that those Disincentives

24:07

will end up getting stronger over time ? Because right now

24:09

they feel fairly soft and I get the

24:11

Sense that part of that's because it's

24:13

still taking people a little while to get to the point

24:16

where they have the tools , they have

24:18

the infrastructure to not be blocking

24:20

, not be providing info blocking . So

24:23

do you think that over time

24:25

you will start adding to that disincentive

24:27

? I mean , a thousand dollars , that's just that's

24:29

a write-off right for some certain smaller

24:31

providers , and even a couple hundred thousand

24:33

dollars isn't a huge impact to the

24:35

revenue stream for a lot of these organizations . They're

24:37

bringing in , you know , hundreds of millions of dollars

24:39

in that patient revenue . So

24:42

Do you think you'll have to

24:44

implement something with a little bit more bite going

24:46

forward , you know , after this initial rule

24:48

gets pushed through ?

24:50

Yeah , I mean I think it's , you know it's hard to know . I

24:52

mean we , you know it's hard

24:54

to know what's . You know what's soft and what's hard . Because

24:58

you know there is one other aspect of it that , from a

25:00

transparency perspective , onc

25:03

, on our website , will post

25:05

or publish the names of all

25:07

the organizations who were found to

25:10

Be

25:12

. You know , I'm not in compliance with the information blocking

25:14

regulations , so there's be a public

25:16

aspect to it as well which could affect

25:18

our hand . And you know , and all that , it's about

25:20

transparency . I mean it's not , it's not disincentive

25:23

per se , it's about just creating transparency

25:25

for the market . But there's that dimension of

25:27

it as well . I think you know we will always

25:29

, will be closely monitoring it for sure

25:31

. And if the eye , if you know , if it looks

25:33

like there's more needed , then

25:36

I think we would always have the opportunity , you

25:39

know , to say well , we're gonna up the you know we're

25:41

gonna up the penalty or find different ways of

25:43

having penalties that have that

25:45

. Have you know more bite ? If you know If

25:47

that's , if that's , you know how it

25:49

looks like it's playing out .

25:51

Okay , make sense . So , obviously

25:54

, in your role , you're talking to a lot of different lobby groups

25:56

. You're talking to different individuals , you're

25:58

doing the speaking circuit , you're hearing

26:01

, you know you got to keep tabs on what's going on with the market

26:03

and where people are thinking on . You

26:05

know the patient side , the provider side

26:07

, the payor side , everybody . So , taking

26:11

into account all those conversations that you're having , what

26:13

are some common themes that you are seeing

26:16

emerge about how different stakeholders assess

26:18

the value of health data technology ?

26:22

No , I think in general and

26:25

I may be just hearing things that

26:27

I want to hear , so we're always

26:29

to be conscious of that but

26:31

in general I feel like

26:33

there is a lot of excitement to

26:36

finally start to get some stuff

26:38

done . But I think we

26:41

feel like it feels like across the board

26:43

, there is a sense that we've spent a

26:45

lot of time converting

26:47

from paper to an electronic

26:50

foundation , to a digital foundation , and that took

26:52

a lot of time and , yes , it was messy

26:55

all of that . But

26:58

in something like 10 , 12 years we've

27:00

completely converted the

27:03

most complex sector of the biggest and most

27:05

complex economy of the world from a

27:07

paper-based system to one that

27:09

is in many , many ways

27:11

, starting to become digitally native , and

27:13

that's a tremendous , tremendous accomplishment

27:16

, and I think

27:18

people don't get enough credit for that , both on

27:20

the public and private side for that

27:22

. But

27:25

I think , that being said , now

27:27

we want to be able to say well , yes

27:29

, you had to get billing done right . Billing

27:32

has to get done . People have to get paid If

27:34

you're not , if those systems don't do billing . My experience helping

27:36

to implement thousands and thousands and thousands

27:39

of electronic medical records was in those

27:41

implementation implementations

27:43

. The minute that revenue cycle had

27:46

a hiccup was the minute that you lost

27:48

everyone . They were like time

27:50

out . We are not doing this . I don't give a shit

27:52

about your EHR , I don't give a shit about

27:54

your vision , but I'm not getting paid anymore

27:56

. So , and that means my nurse isn't getting

27:59

paid , my front staff isn't getting paid and my janitor is

28:01

not getting paid . No one is getting paid . So

28:03

you need to make sure that , first

28:05

and foremost , we're getting paid . I know people criticize

28:07

oh , these are billing systems . It's like well , all

28:10

right , let's ask every one of you do you like getting

28:12

paid or not Not getting paid ? If you don't like

28:14

getting paid , great , fantastic

28:16

, come and volunteer , implement this technology

28:18

on behalf of society and

28:20

don't get paid in the process . But

28:23

so people need to get paid . Yes , we

28:26

need to convert from digital , from paper , to digital . Yes

28:28

, but I think all of us have higher ambitions

28:31

for this . How is this actually going

28:33

to help with curing cancer ? Cancer

28:36

moonshot goals , 50% reduction in

28:38

the next 10 years , or I forget the specific goal in

28:41

cancer , those kinds of things

28:43

. Improvements , significant , substantial improvements

28:45

in public health , maternal health

28:47

all of the things that we're kind of focusing

28:50

on , I think , is where there's

28:52

genuine excitement Just say let's get to that next

28:54

level , let's get to the level of being

28:56

able to say we're now past

28:58

the trough of disillusionment in the Gartner

29:00

hype cycle and we're on the path of the

29:02

slow of enlightenment and let's sort

29:05

of grab that opportunity . So that's kind of

29:07

where I feel like there's a tremendous

29:09

amount of excitement and

29:11

it sort of comes through and

29:13

enthusiasm we've gotten for the US CDI

29:15

, that minimum data set , us Core Data for Interoperability

29:18

both in the market as well as across

29:20

our federal agency partners . The

29:22

enthusiasm we're getting for Tefcom that

29:25

just went live and happy

29:27

to talk more about that , and the enthusiasm that

29:29

we're getting for all the work we're doing to

29:32

make sure that FHIR API

29:34

adoption is moving forward

29:36

aggressively to finally

29:39

have healthcare firmly

29:41

discover the internet in the ways

29:43

that almost every other sector .

29:44

I mean it's still kind of crazy that not

29:47

everybody has online scheduling tools for their

29:49

organization yet . Right , getting back to that

29:51

kind of payment piece , so

29:54

real quick , kind of sidebar question that isn't super

29:56

relevant to the rest of this discussion

29:58

, but do you think that RCEM

30:01

solutions are going to be necessary post

30:03

fee for service ? So if we're actually able to make a full

30:06

transition to value-based care , do you think that those RCEM

30:08

technologies are still going to be relevant ?

30:12

Yeah , I mean , I'm not an expert in

30:14

that , but

30:17

in theory you can imagine that

30:19

they would take a different flavor . But

30:22

we're pretty far away from our goal of having

30:25

everything in value-based care . So I think

30:27

there's going to be a new

30:30

RCEM solutions for a long time

30:32

.

30:32

No , absolutely , but thinking about that being

30:34

one of the first big needs for digital and

30:36

why a lot of the EHRs and

30:39

core systems are so flat and not necessarily

30:41

systems of engagement or , more just , systems of

30:43

record . But as we think

30:45

about that shift away from fee for service , hopefully

30:49

I see some of that investment going more towards

30:51

tracking , value measures and the other kind

30:53

of performance metrics that are going to be tied to

30:55

value-based care , and I think

30:57

that's a really important capitation .

30:59

But to your point , that's just a different flavor of RCEM . My

31:03

experience in implementing was

31:06

pretty consistently been that when

31:10

organizations move from fee for service

31:12

to some kind of value-based

31:14

purchasing arrangement , whatever it is , is

31:16

the minute that they really start focusing

31:18

on interoperability , because

31:21

it's moved from overhead to

31:23

my cost

31:26

of good soul essentially it's

31:31

a part of doing business at that point

31:33

and to delivering

31:35

value , and

31:37

so I generally agree with you that that's

31:40

sort of one of the biggest drivers

31:42

of being able to think more creatively and innovatively

31:44

about how technology can really

31:47

deliver value versus just getting the

31:49

bills paid .

31:51

Yeah , enable new models of care , enable just

31:53

performance improvement , ongoing

31:55

consistent performance improvement , specifically

31:57

, et cetera . So

32:00

, getting back to your training as

32:02

an economist , why

32:05

do you think the value assessment has been

32:07

so hard to achieve in a consistent

32:10

manner in the healthcare tech

32:12

space for so many years ? Obviously

32:15

, it's a relatively immature space , so that's part

32:17

of it , the immaturity . We

32:19

didn't have the data to effectively assess the

32:21

impact . But what else is going on here

32:23

that's made it so hard to actually assess

32:25

the value of IT and healthcare ?

32:29

Well , I think it's a little bit of what we were talking about . That

32:34

, first off , it's in a fee

32:36

for service . World interoperability

32:39

and indeed in many parts of health

32:41

, information technology are just overhead

32:44

. I mean , you're basically

32:46

in a cost plus contract

32:48

kind of arrangement and there

32:50

aren't huge incentives

32:52

to get more efficient

32:55

and or deliver higher value , and

32:59

so I think that's just one of the challenges that we

33:01

have . And again , I don't think

33:03

it's different than any other business . It's just that

33:06

that's kind of the way that a lot

33:08

of the economics flow in

33:10

healthcare . So I think that's been one challenge

33:12

for sure . I think that

33:14

the opaque nature of

33:16

healthcare

33:19

economics is also right

33:21

, and this is like in every healthcare

33:23

economics 101 or in every economics

33:25

101 course you'll get is

33:27

well , here's how markets work , and then let's

33:29

talk about markets that don't have

33:31

some of these core sort

33:34

of principles . So meet these core principles

33:36

of plausibly efficient markets

33:38

, and healthcare and defense are the two right

33:40

that every single economics processor across

33:42

the country teaches . And

33:45

the part of the healthcare equation is that

33:47

consumers are shielded

33:49

essentially from the

33:52

purchase decisions that they make in

33:55

certain significant ways , that

33:57

there are information and symmetries . It's really

33:59

hard for them to assess value and

34:01

to assess incremental value for the incremental

34:03

value of the next unit of payment . And

34:09

also there is a very asymmetric view of

34:11

risk , which is actually very similar to defense

34:13

, where I did a lot of work with the defense industry I was talking about

34:16

before . It's very similar in defense right

34:18

, where you don't have sort of a symmetric

34:20

idea of risk . No-transcript

34:22

risk , wait a minute , I increase my risk of

34:25

dying five percentage points . That's

34:27

not good , that's

34:29

really not good . In the same way , with defense

34:32

, we're always like wait a minute . Every

34:34

increment in risk you're adding is a

34:36

risk to our entire country and our entire way

34:38

of life . That's not good , right ? So

34:41

we do everything that we can to move

34:44

away from that risk and to be very risk

34:46

averse . On that dimension , healthcare

34:48

is very similar , I think , and individuals behave

34:50

that way . So I think that's part of the challenge is that

34:53

it doesn't have those

34:56

simple or relatively simple kinds

34:59

of value metrics that we can apply in other

35:01

parts of the economy

35:04

. I think the other part of this

35:06

which makes it especially challenging is

35:09

that it's a very

35:13

fast moving technology space and

35:16

so for anyone who is

35:19

trying to say well , I'm going to cut

35:21

, people

35:23

say this all the time we're going to reduce the cost of care

35:25

. It's like , well , we're not really going

35:27

to reduce the cost of care , we

35:29

hope to reduce

35:31

the increase in

35:34

cost

35:36

growth . We hope to

35:38

be more productive or efficient

35:41

, meaning that we are getting more healthcare

35:43

quality per unit dollar

35:45

that we're spending . But

35:48

those aren't obvious things , right ? Those are

35:50

not obvious things to measure , particularly

35:52

when healthcare quality has

35:54

got many

35:57

, many , many non-monetary aspects . What

36:00

is the value of an

36:02

improvement in my quality of life so

36:05

that I have

36:07

managed diabetes , for example

36:09

, or I don't have my leg amputated , or

36:13

any of those things that are about my quality

36:15

of life ? How do we actually measure that in

36:17

a way that enters that

36:19

value proposition equation

36:22

in the same way that it does when I purchase

36:24

a computer or a TV

36:26

, where you can have that price

36:29

quality chart and it's pretty easy

36:31

to make those estimates of demand supply

36:33

and what additional value

36:36

you get for that next

36:38

increment in capability

36:40

in my TV or my computer

36:42

. I think all of those things make it really

36:45

hard to have that kind of calculation .

36:48

Yeah , I completely agree . That's something that

36:50

at Chillmark we've been watching play out since we first

36:52

entered the space . It's a

36:55

conversation that hasn't been as

36:57

tantamount to the

36:59

activity in the industry , because for a while there

37:02

we founded the company shortly before Hightep

37:04

got passed For

37:06

a good chunk of the last decade people were

37:09

focused on that area , on meaningful use , on

37:11

just core infrastructure getting implemented , getting

37:13

the government incentive payments

37:15

for implementing this core infrastructure

37:17

. I think that now that

37:20

some of that money is dried up and there

37:22

isn't as much new money coming in

37:24

for core infrastructure investments

37:27

, you are seeing the tight

37:29

margins and the financial constraints of

37:32

healthcare organizations really come into play , with more

37:34

of these decision-making and having

37:36

to much more align any new investments with

37:39

their own organizational strategy versus some

37:41

outside strategy that's being pushed onto them

37:43

.

37:44

Right , I think that's the nature of the public

37:46

goods problem I think you just

37:49

said it which is that no organization for

37:51

all of these organizations they feel like

37:53

, well , it's not , how much

37:55

additional value do I get by

37:57

that next incremental investment

38:00

in interoperability to

38:02

get that next increment of information ? And

38:04

for most organizations they'll be like

38:07

pretty low . I'd rather just ask the patient

38:10

Right

38:12

which is not the best way of doing this

38:14

, and I would argue that that's

38:16

one of the aspects of public goods that

38:19

the federal government needs to sort of help

38:21

to solve that inefficiency

38:23

, that market failure or

38:25

dimension of a market failure . That is a public

38:28

good . What is the value to our country

38:30

of having an effective public health system

38:32

? What's the value to our country

38:34

of having patients have

38:36

as much information available to their

38:38

providers to provide the best

38:41

possible care ? Those are all

38:43

public goods that the market itself

38:45

is not going to value in the ways that we

38:47

, as a country , I think should want the

38:49

market value .

38:52

Yeah , I think that's a really good way of putting it . And

38:54

so that kind of gets into the

38:57

next section of this discussion , which we're

38:59

recording this a few days before

39:01

Christmas 2023 . And last

39:03

week you guys had a very busy week

39:06

with your annual ONC

39:08

conference , the first one since 2019

39:10

. And you had a whole bunch of news coming

39:12

out over the last week and a half . So QHINZ

39:15

went live . Hti one final rule

39:17

came out . You got your AI

39:19

transparency element got added into HTI

39:22

one from the initial proposed rule . So

39:24

can we start at the top and just you

39:26

know what's the big deal about QHINZ ? Just a quick

39:29

summary of why this is so exciting , why it's been

39:31

such a big focus of the government for the last few years

39:33

making this happen and getting us to the point that we are today

39:35

.

39:38

Sure , really , since the founding of ONC

39:40

in 2004 , there's

39:42

been the vision of essentially a nationwide

39:45

network for

39:47

medical record interoperability and

39:51

you know there's a need for some type of governance

39:53

for that . If you look at any other network

39:55

, any other industry , there are networks

39:57

that provide that backbone

39:59

of assurance for

40:02

reliability , for trust , for security

40:04

, for , you

40:07

know , collaborative problem solving

40:10

that are important to

40:12

you know , make sure that you've got that

40:14

you know sort of the backbone

40:17

to have information sharing , to

40:20

make sure that information gets where

40:22

it needs to get when it's needed

40:24

. And if you look at , you know , banking

40:26

system , for example , ach payments , right

40:28

, there's a huge , you know

40:30

sort of infrastructure behind the scenes that makes

40:32

sure that when I do my Benmo

40:35

payment or I write a check or I do a credit card

40:37

transaction , that all that gets reconciled

40:39

on the back end and I don't have to worry

40:41

about it as an individual . We don't , you know we've

40:43

been building toward that . In healthcare we

40:45

had some HIEs

40:47

early on , indian Health Information Exchange , which I

40:49

you know , which I've found , you know was

40:52

one of them . And then we had

40:54

the ONC program which looked from

40:56

a geographic perspective and sort

40:58

of made an assumption that , well , each state

41:00

will have an HIE and then

41:02

those HIEs will get , you know , connected up

41:05

as it turned out . You know that isn't the way it worked . Some

41:08

states , you know geography

41:10

was a good basis for health information

41:12

exchange network in

41:14

some places , but in most places

41:17

it actually wasn't a great you know sort

41:19

of dimension of affinity or you know sort of

41:21

a vector of trust , however you want to think

41:23

about that . And so then we moved to

41:25

the next level , which is you've got some

41:27

state you know on regional HIEs

41:29

but more nationwide type of

41:32

networks forming the health exchange which spun

41:34

out from the federal government . Care

41:36

of quality , the Commonwealth of Health Alliance , epics

41:39

, care Everywhere , for example , obviously

41:42

was , you know , was designed for , you know with an EPIC , but all of

41:44

those you know kind

41:46

of really being more organic efforts

41:48

to say , where is the business connection that we have here ? And

41:52

then how do we build on that to create a network to support

41:54

you know , to serve our participants ? So we're at the point now that we've got you

41:56

know sort of a number of networks and

42:00

the direction from the 21st Century

42:02

Cures Act was to , you know , try to

42:04

once and for all say all

42:06

right , at this point we need to connect

42:08

them up so that we have the user experience , the

42:11

network of networks , user experience , so that whichever

42:14

network you're on , you will be connected to

42:16

everyone else for a basic set

42:19

of , you know , of services , that basic interoperability . And that's

42:22

what we've been working toward and , again , that's you know . If you look at the phone

42:24

industry , it went through

42:26

a very similar type of process . There

42:29

was , you know , for there was a long time where you

42:32

know , the old Ma Bell AT&T , you

42:34

know , covered , you know , I actually

42:36

know this information because I did some research on it

42:39

and I like to talk about it . Like , in the early 1900s

42:41

there were something like 2 million phone

42:43

users across the country , which itself

42:45

was , I think , just sort of shocking that there were

42:47

that many phone users , but something like 50%

42:50

of them were connected in the

42:52

AT&T network , the old Ma Bell network

42:54

, right ? So you got about a million or

42:56

maybe it was a little bit more . Maybe it was like two thirds were

42:58

connected on the Ma Bell network , one

43:01

third remaining , one third

43:03

were covered by

43:06

over 2,000 networks . So

43:09

you think about that sort of feels

43:12

a little bit like we are today , right , you've got a couple of big

43:14

networks and then you have a whole bunch of small networks

43:16

. Then the problem for us as a country

43:18

was to say all right , how do we connect up all those networks

43:21

? That took like 50 years . In

43:23

telephone history it took like 50 years for

43:25

that to all be consolidated in

43:28

a network of networks type of structure where

43:30

, whether I use AT&T or

43:32

Verizon or T-Mobile or Sprint , I

43:34

don't for a second worry about whether I

43:37

will be able to talk to someone on another phone on

43:39

another proprietary system . That's

43:42

what we wanted to be able to do with Tefka and that was the direction

43:44

we got from the Congress to build . So

43:47

that's the importance of these networks . You can think

43:49

of them almost as like the AT&T , verizon

43:52

, t-mobile and Sprint of medical

43:54

record interoperability . You've got to have

43:56

some organization that's already got a network

43:59

and you want to connect them up to

44:01

solve that problem network to network

44:03

, when they're already providing services within their

44:05

network . So we had five organizations

44:08

who stepped forward to do this voluntarily . There

44:11

was nothing in the 21st Century Cures Act that gave us

44:13

either funding or authority , meaning

44:15

the ability to tell everyone

44:18

in the country you are required to

44:20

join this network . We didn't get any of

44:22

that direction from the Congress . So we

44:24

really needed to put it together as a model

44:26

that the industry saw

44:28

as being valuable from an industry perspective

44:31

, and I think what you see is these

44:33

five organizations , as well as two who

44:35

are in the last stages of their

44:37

implementation . Plus we've got a couple who

44:39

are in the application stage , two more

44:41

who have publicly announced very large

44:43

, influential organizations who have announced

44:45

that they have submitted their applications and intend

44:48

to become qualified networks as

44:50

well . That starts to sort of fill

44:52

out that idea of we've got

44:54

some networks that connect with

44:56

each other . Regardless , if you're a provider

44:58

, if you're a hospital , regardless of which network

45:00

you join , you will have the confidence that

45:02

you can exchange information with anyone else

45:05

, regardless of which network they're on .

45:08

So can you just give me a quick overview

45:11

, very brief , of what exactly

45:13

the data is that is going to be included

45:16

in the QHINs , because it's not

45:18

going to be all the data . There's a lot of unstructured data

45:20

. There's still pending

45:22

standards coming out for USCDI

45:24

. So at this

45:26

point in the development

45:28

of the QHIN concept , what data

45:30

elements and what exchange is actually

45:33

happening on this national network ?

45:36

Sure . So the requirement

45:38

in theory is

45:41

EHI Electronic Health Information

45:43

which is basically

45:45

the same definition that's used for

45:47

the information walking rules

45:49

, which is basically all electronic

45:51

health information . But we recognize

45:54

that that's really hard to do when you

45:56

don't have standards for all of that , and

45:59

so the minimum expectation

46:01

, the base expectation , is that

46:03

what's exchanged is the US core data

46:05

for interoperability , the USCDI , and

46:08

that's required by EHR vendors

46:11

. It's required in various federal programs

46:13

to be supported for quality measures or other

46:16

things , so it's kind of the

46:18

minimum data set of the healthcare delivery system . Already

46:20

I will note that the USCDI does

46:22

have eight note types in it as well

46:24

. So it's not as if the USCDI is only

46:26

structured data . It's not . It

46:28

includes notes , eight

46:31

note types that are required to be supported as part

46:33

of the USCDI . So that's the

46:35

minimum expectation , that that's what will be exchanged

46:37

. Again

46:40

, the requirement and it's a loose requirement

46:42

is that you send whatever you have electronically

46:44

. We just think

46:46

that we can have a good expectation that everyone

46:48

can send the USCDI , because that's

46:50

what most of those networks do today . In some

46:52

way , shape or form , they send the USCDI and

46:55

we expect that that would grow over time and certainly the information

46:57

blocking rules will provide

46:59

added impetus for people to share

47:01

more information than the USCDI , because the

47:03

information blocking rule is not limited to

47:05

the USCDI . It's limited to everything electronic

47:08

, everything in quotes , because that's

47:10

a pretty hard term to get your head around

47:12

. But

47:15

as the information blocking rule sort

47:17

of comes into place and people start

47:19

to , with enforcement and all of that coming

47:21

into place , we think

47:23

that the TEFCA would replace that . Organizations will feel like , okay

47:27

, I can share more and more

47:29

of that electronic information in the TEFCA network

47:31

and then I

47:33

will be complying with the information blocking or substantial

47:35

portions of the information blocking regulation because

47:38

I'm just making the information available and

47:41

it'd be pretty hard at least for the information

47:43

that someone's asking for , could be

47:45

pretty hard for someone to make a case that I'm information blocking

47:47

If they're on TEFCA

47:49

and I'm on TEFCA and I'm making this information available . That helps

47:51

from a compliance perspective as well . So

47:55

we think that that adds added impetus

47:57

for people to want to do it .

48:01

Okay , so we're getting a little bit late in the recording session so

48:03

I've got to jump through some of these a little bit

48:05

fast . I

48:08

think in general , most people can look

48:10

up HTI1 and see the summary that other folks have put out . I'll

48:12

share a couple of those in the show notes , but

48:15

can you just give a really quick overview

48:17

of what exactly

48:19

is contained in HTI1 ? And

48:23

how you perceive the evolution

48:25

of this ? Because the organization

48:28

has telegraphed out that

48:30

HTI1 is the first of these new certification

48:32

requirements and there's got to most

48:35

likely be an HTI2 in 2024 . I

48:37

mean that's going to be dropped in 2024

48:39

for commentary to be implemented 2025 . So

48:42

, as we think about the evolution

48:44

of these new rules for certification

48:46

, how do you think that will evolve and what exactly

48:49

are we starting with and what do you

48:51

see as being the next steps ?

48:53

Sure , yeah , so HTI1

48:55

isn't just about certification but it's

48:58

got . I mean , certainly certification is a big part of it , because

49:00

there are some things in there on information blocking

49:02

which technically isn't about certification . That's a whole

49:04

different thing which is information blocking , but

49:08

the things I mean there are many things . It's a 958

49:10

page rule , I think . So there's lots of things in it and

49:14

but you know , things that I would point to

49:16

as being really significant , I think , are

49:20

three things . One is the

49:23

establishment of the USCDI version

49:25

3 as the baseline

49:27

standard for the minimum data set , essentially

49:30

for the industry , because that includes pretty significant

49:32

health equity related data elements

49:34

that weren't a part of the USCDI

49:36

. That you know , that we inherited coming

49:38

in and so you know . So that's

49:41

a pretty big deal and you know the industry has been asking

49:43

for that , federal agency programs

49:46

are asking for that , so that's a really important part of

49:48

it . The second is it's the

49:50

first , you know , set

49:52

of regulations that this administration

49:55

has put into place related to AI

49:57

and healthcare . There's obviously

49:59

already different regulatory mechanisms you

50:02

know that are in place . You

50:04

know OCR I shouldn't say it's first , I mean OCR

50:06

has draft rule related to non-discrimination

50:09

in the use of AI-enabled tools . Fda

50:12

regulation has been placed for many years . That does

50:14

, you know , have authority over medical

50:17

devices that have AI-enabled

50:19

features in them . But this is a , you

50:21

know , pretty substantial regulatory

50:24

step forward , specifically with regard

50:26

to AI and healthcare and the requirement

50:28

there is for transparency . It's

50:30

really to empower clinicians , whether

50:34

it's physicians in physician offices or in

50:36

hospitals . It's to empower them

50:38

so that they have better

50:40

awareness of the AI-enabled technologies

50:43

that are embedded in their electronic

50:45

health record system and

50:47

to give them some information

50:50

so that they can make better judgments about whether

50:52

that particular AI-enabled tool is

50:55

appropriate for in their particular

50:57

setting . So it's really not about regulating

50:59

the AI-enabled tools themselves . We're not assessing those . We're

51:03

not monitoring those . What we are doing is saying that if

51:05

you have an AI-enabled tool in your

51:08

electronic health record system , you , as the EHR

51:11

, have a responsibility to

51:13

make available information

51:18

that will allow the user of your system

51:20

to judge whether that particular AI-enabled tool makes

51:23

sense in their environment . And then the third thing that's

51:25

part of the rule was that the

51:27

statutory requirement that came from

51:29

the 21st Century Cures Act , which is

51:32

a new kind of

51:34

program called the Insights Program

51:36

, which requires that electronic health

51:38

record vendors produce

51:40

information that

51:42

will be aggregated and made available

51:44

publicly . That gives us a sense

51:46

of where are we with the EHR

51:49

implementations and interoperability . So

51:51

how do we think at an industry level , like an industry

51:53

level dashboard of health information

51:56

technology adoption and use

51:58

and again , that was a statutory

52:00

requirement , so it was required that

52:02

we put that into place and

52:04

the first set of measures that

52:06

we are proposing to be part

52:09

of that dashboard are part of that HTI one

52:11

.

52:14

Okay , so I have one

52:16

final question that that all raised

52:18

. I had a whole bunch more questions

52:20

in our discussion guide but due to limited time

52:22

there's only so much we can cover . But

52:25

a few weeks back the

52:28

White House , the Biden-Harris administration

52:31

, released their SDOH playbook and

52:33

earlier this year at a congressional briefing , you stated

52:36

that quote . We are

52:38

really thinking about health equity as a core

52:40

design principle , starting

52:42

with the data itself . You've got to have that data

52:44

available in order to be able to identify where

52:46

there might be communities that are getting different types of care . So

52:50

how much does that tie into

52:52

this new SDOH playbook initiative and

52:54

how much is the

52:57

ONC involved with the development

52:59

of this playbook ? That is supposed to be if they're

53:01

able to pursue their dream

53:03

. As it's laid out , it's supposed to be an all-of-government

53:06

initiative , pulling in data from

53:08

various disparate sources to better identify

53:10

what are the social ails

53:12

that can be traced back to social determinants of health

53:15

and health resource needs . So

53:18

can you talk a little bit about ONC's

53:20

role in moving that forward and

53:22

scoping that out ?

53:24

Sure , so , yeah , so we were very

53:26

involved from minute

53:28

one of the SDOH . It

53:30

was what's called an IPC , an Inter-HC

53:32

Policy Committee , that created the

53:34

SDOH playbook . So

53:37

it's , you know , ipcs

53:39

are kind of , you know , sort

53:41

of started or initiated

53:43

by the White House , someone in the White

53:45

House or a group in the White House and , as the name

53:47

implies , it brings together federal

53:50

agencies together to

53:52

work on a particular area . And in this case , sdoh

53:54

was , you know , was there , there was one for AI and

53:56

there's , you know , others on the many of them , but

53:59

this one we were involved in , you know , literally

54:01

from the very beginning , as they were

54:03

just forming the IPC . We

54:07

were directly involved with them and , you know , trying

54:09

to sort of think about how we think about this from

54:11

a health and information technology perspective , because

54:13

, obviously , electronic health records and interoperability , but

54:16

you , I mean you , can't have a healthcare

54:18

discussion meaningfully , I would

54:20

argue , at this point , without talking

54:23

about the health information technology aspect

54:25

of it and how that will either enhance

54:28

or , you know , be a detriment

54:30

to whatever it is you're trying to accomplish . And then how

54:32

we can , you know , sort of figure out how to , you know , make up

54:34

something that's helping to advance . You

54:36

know , important policy objectives . So when

54:38

you look at the SDOH playbook , I think you see significant

54:41

portions that talk about interoperability . It talks about

54:43

, you know , social and mental health . It talks about

54:45

the importance of having the USCDI , you

54:47

know , be a core construct of that . As

54:50

I mentioned before , you know , having the USCDI version

54:52

3 is a really important step forward

54:54

because that has those health information , that

54:56

health equity data elements that

54:59

all of us are looking for to be able to build

55:01

programs around . First we're going to identify

55:03

where there are issues and then , second , to be able to have

55:05

programs , you know , built , leveraging those data elements

55:07

. And you know , uscdi

55:09

version 3 , assuming that it becomes

55:12

well , it is actually we've

55:14

got the final rule out it will now

55:16

, you know , become the basis for

55:18

Tefka exchange , for example . We start with USCDI

55:20

1 because that's what we have , but that

55:23

will up to USCDI version 3 , which starts

55:25

to have those data elements that allow us to

55:27

be able to have that health equity by design kind

55:30

of construct . That it's starting with the data and then you build up from

55:32

there .

55:35

Okay , yeah , I mean I would

55:37

love to talk to you more about the SDOH playbook

55:39

and how much staying power

55:41

that has post this administration

55:43

, because I think that's one of the big unknowns right now . No-transcript

55:49

. I think that there's a huge need

55:51

for that across healthcare . But figuring out the kind of economic

55:53

model for that , While

55:58

we're still operating under largely fee for service

56:00

kind of infrastructure , I think that's a huge need

56:02

for that across healthcare . But figuring out the

56:04

kind of economic model for that While

56:15

we're still operating under largely fee for

56:17

service kind of infrastructure , is something that you and I could probably talk about for

56:19

days . It's such a big need and such an interesting area . So maybe

56:21

that's maybe we can have a follow up conversation

56:23

on that sometime in the future , but for now , thank you so much for joining us today

56:26

, Mickey , Particularly as we

56:28

explore the many ways that industry stays in the future

56:30

, and I think that's a really important part of the process . So

56:35

if any of our listeners want to be more involved with the process

56:37

of developing new policy , how would you advise they go about making their

56:39

voices heard ? How would they get involved with the government

56:41

? Yeah

56:45

, I mean there's a variety of ways , you know . Certainly . We

56:47

meet with stakeholders all the time , so we're always happy to do that . Our

56:50

high tech , which is our federal advisers , we're always happy to do

56:52

that .

56:54

Our high tech , which is our federal advisers committee

56:57

, does everything in public , both the full committees as well

56:59

as the subcommittees , and always at every meeting has

57:01

an opportunity for public comment . So

57:03

I think , getting on our website looking up the high tech and

57:05

there's a number of different work groups there and people

57:08

are interested in that that's

57:18

a great opportunity to sort of , you know , just dive

57:20

in deep on the policy issues that we're contending

57:23

with and be able to offer the opportunity to provide

57:25

public comment , all of which is recorded

57:27

, and you know that we always take into account .

57:30

All right . Well , there you have it , folks . A big

57:32

thank you for Mickey Tripathi for taking this time

57:34

. I know that December is always busy

57:37

for everyone , so I really appreciate you meeting

57:39

with us to record the session and sharing your expertise with us . Happy

57:44

holidays and have a great new year .