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January 12th, 2024: This conversation with Micky Tripathi, National Coordinator for Health Information Technology at ONC, explores the intricate balance between policy, technology, and business within healthcare. How is the intersection of these domains reshaping healthcare IT, and what challenges and rewards come with navigating this nexus? They also touch upon the implications of the 21st Century Cures Act and the role of information blocking in modern healthcare. What does the future hold for health IT professionals in the wake of these regulatory changes, and how will these adjustments impact patient care and provider interactions? Furthermore, the discussion highlights the potential of TEFCA (The Trusted Exchange Framework and Common Agreement) in revolutionizing health information exchange. Could TEFCA be the key to overcoming previous communication barriers in public health emergencies? Join us as we explore these pivotal topics and their implications for the future of healthcare.

Key Points:

  • Home Based Care
  • Information Blocking Regulations
  • TEFCA and Public Health
  • Patient and Provider Interaction
  • Ethics of Sharing Information

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Transcript

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

  Today on This Week Health.

(Intro)  I would ask them, do you really want to work in the healthcare industry? if you consider that intellectual property that you think clinicians should not have information about before they're making life and death decisions on patients, then you're probably in the wrong industry.

Thanks for joining us on this keynote episode, a this week health conference show. My name is Bill Russell. I'm a former CIO for a 16 hospital system and creator of this week Health, A set of channels dedicated to keeping health IT staff current and engaged. For five years, we've been making podcasts that amplify great thinking to propel healthcare forward. Special thanks to our keynote show. CDW, Rubrik, Sectra and Trellix for choosing to invest in our mission to develop the next generation of health leaders. Now onto our show.

(Main)  All right. It's a keynote and we're excited to be joined once again by Dr.

Mickey Tripathi, the National Coordinator for Health IT. MIckey, welcome back to the

show. Thanks, Bill. Really glad to be back.

You've been busy, and it's not even an election year yet does an election year change your role at all, or is it's just consistent?

Yeah, I've never been here during election year, so I actually don't know.

We we're just working as hard as we can to get as much done as we can. We are going to

blink, and it will be January. And in fact, this will air in January, so by the time people are listening to this, it will be pretty much in the heart of an election year.

So we'll see what happens. I wanna start with personal. We're gonna talk about, we'll talk about Teca, we'll talk about HTI one, we'll talk about ai, we'll talk about all those things. Obviously hit policy and things that are coming. But I wanted to start with just a question for you.

You're in this role.

You have extensive experience in in healthcare and healthcare IT. What's been the most rewarding aspect of your work in this role? And what challenges do you find, the most invigorating to tackle in that role?

yEah, I think, certainly the, at least for me I've always been interested in, the nexus of policy technology and, business.

And so that's, been an exciting part of this role because, we are front and center of, all of those things. And I think at least the rewarding, that's tremendously rewarding to be able to work on, the nexus of those things as they come together and to figure out how to put them together for the people.

And I know that, it sounds a little bit, Pollyanna ish but I've always been, pretty mission oriented. and I, this is not my second, this is not my first tour of the federal government. I worked in the federal government a while ago. And and did take a lot of, sort of gratification in, in knowing that I was, working on behalf of the taxpayers and on behalf of the American people and. with my government colleagues who are just, tremendously mission oriented. I think government bureaucrats as people like to call them are tremendously undervalued in my experience. There's just a tremendous amount of dedication and expertise. and experience there that that that Americans should be proud of.

And I think any American who actually took a job in the federal government, I think just like when we do jury duty, I think most people come away from jury duty and they're like, wow, I actually feel better about the government. I Don't know if that's your experience, but people feel more patriotic when they do jury duty.

And I have that feeling and, when you join the federal government as well. So that's certainly been gratifying. What

would be the most surprising thing? I, think as I got more involved in the policy, I was surprised how much input comes from the outside. public private interaction, I think, surprised me as well.

I didn't realize there was as much. Of that, what other things might surprise people about the process and how these things essentially get out into the health IT community?

Yeah, a couple things. one of the things that's surprising to me since, I was in the private sector for 20 years.

In health IT before coming into the federal government. My prior federal experience was in the Pentagon. And so that had a whole different way of interacting with the public, right? So that wasn't a really a good model for, how do you have public private kind of collaboration.

But I think one of the things that was surprising to me is how easy it is to end up, being behind the federal wall and be insulated. from what's going on in the market. And I've tried to, do everything I can to have ONC be, even more, outward facing as we can be and more interactive with the market and with the community to be able to get that kind of on the ground feedback and on the ground input because that's where the action is.

The people who are actually implementing this stuff day to day the people whose stuff whose lives are being directly affected by the things that we're doing. I think it's really important for us to keep as close a pulse on that as possible. And just in my experience, it's really easy to, be behind the federal wall, and all of a sudden you're, you've lost track over things that move really fast in the market.

guess the other thing I would just point to that's been, surprising in a good way, is I think that individuals and individual leadership can play a big role. in the federal government, and I think people don't appreciate how with the right leadership, and I would point to, Secretary Becerra and Deputy Secretary Palm and and, and all of my colleagues leading the operation divisions, operating and and staff divisions, that when individuals start to focus on very specific things and set priorities and roll up their sleeves and try to You know orchestrate the things to make those things happen.

Things can actually happen but it takes that kind of dedication. It takes an appetite for bureaucratic ninja work which is, not in a bad way. Every even private sector companies have bureaucracies and you have to navigate all of that stuff. So I think that's been surprising as well as how much you actually can accomplish, but you do have to set your priorities.

Over a cup of coffee at a later date and not on the air, I'd love to hear. The interesting thing to me when you get into

these kinds of public roles is,

How much do you read the press clippings because, some are positive, some are negative. We'll talk about that another time because I think that it's interesting because, rarely do you get accolades through the media.

It's always the opposite. I wonder how much of it's just I'm going to stop reading the newspaper for a month just do my job. Anyway,

It's a dynamic time to be in your role. It's a dynamic time to be in this space. Obviously we have a lot of movement with algorithms with AI HDI one proposed rule. I actually, let's start with this. Could you give us an overview? of HTI 1, the proposed rule and its significance to health IT professionals.

Sure, yeah, there are a couple of things in in the HTI rule is fairly sweeping in terms of covering a lot of different areas.

It's not There are other agencies who have very specific rules, that they have lots of rules and big rules and important rules like CMS has, it's physician payment rule and it's hospital payment rule. And each of those are, very focused in a particular area.

ONC, we're a smaller agency. And then when we do rulemaking, we, have it be like an omnibus kind of rule that has a whole bunch of different things in it related to the different kinds of authorities and the different areas that we work. The HDI 1 rule encompasses a number of different things that I think are really important for your listeners in the audience to to know about.

First is there's a set of proposals in there related to the creating transparency. regarding the use of AI enabled tools in electronic health record systems. As many of us now know, you have to be hiding under a rock somewhere to not have heard that AI is here and it's it's coming at you very fast, and it's certainly entering the healthcare space very rapidly.

The department is actually keeping pace with that. I'm happy to report a lot of work in AI, but the HTI 1 proposed rule actually has a very specific set of regulatory requirements on certified electronic health record vendors, which covers 96 percent of hospitals almost 80 percent of ambulatory practices that would require that they create transparency.

about the black box kind of AI tools that are in those electronic health record systems. this isn't accusing the vendors of hiding this stuff. It's just that a lot of these tools are embedded in the systems and the clinician users may not be aware of, of these tools.

And as they grow, more sweeping in terms of, what they're doing, and they become more pervasive and more influential in terms of the types of decision making that they help to inform. We think it's really important that we lift the veil of that a little bit and provide some information to the customer users.

So our proposal isn't about regulating AI enabled tools. It isn't to say, not like FDA approval. For, for medical devices, we're not proposing that type of regulation. What we're proposing is that the customers in this case, like clinicians, for example, ought to just have information about the tools that are in that system so that they themselves can determine whether using that particular tool is in the best interest of their patients.

And just like they do every day, right? They do that every day with devices and with form, with medications and all that. We're just saying, let's lift that up to that level so that they have that ability to do

that. really fascinating to me just in my work on a day to day basis. All of a sudden, little boxes start showing up in my applications and they say, Oh, what do you want to do?

And I type it in there in natural language and all of a sudden it's doing stuff. And we're seeing that same thing in the EHRs, right? So we saw a lot of announcements from Epic, from Metatech from Oracle. That they are starting to embed this. And I was talking to one and I said, I have a feeling we're going to wake up a year from now and it's going to be pervasive, it's going to be everywhere because every one of our partners right now is scrambling to figure out, hey, can these tools be applied In a new way in healthcare.

And, I mean we had 800 applications. If every one of those partners decided to put some sort of AI functionality in there there's there's a risk associated with that. There's a privacy risk, there's a security risk. There's, but there's also a safety risk.

Is it, are you trying to address all three? Or how are you guys looking

at

it? Yeah, no, it's a great question. I think you, and you rightly point to, the various dimensions of this that, that we all need to be really cognizant of. Yeah, so what our role does is it does two things.

It it requires that the EHR vendors create the capability for transparency of the AI enabled tools. Which tools are in the system, embedded in the system, or interfaced in the system to the extent that they know it. Often the EHR vendor may not know it, but they, but, but what are the tools that are, that meet the definition of AI as we put into the regulation?

And then we are proposing sort of a nutrition label that would need to be made available for each one of those, right? To just open up that box a little bit to give the, to give the user information about what, what was the original intent of the model? What is it supposed to do?

Where did it come from? What was the training data set? So all of these are trained on a patient population, which is what makes them, special in certain ways. But what was that training data set? And that may be, something that you take into account if you're in a particular geography that has, a very specific patient demographic that may be very different.

than the patient demographic that was that was used to train the model. Not that's wrong or right, but it's just something that you may want to take into account as you're thinking about the model. So there's a variety of, categories of what's being done to assess, to identify risks from a health equity perspective, for example, from other perspectives.

Those are the kinds of information that we would expect to see in that nutrition label. And then the second part of it is is a responsibility to have some kind of risk management. framework in place for deciding how AI enabled tools are in the EHR system. And we're not being overly prescriptive on that.

We're basically just saying, we're not telling you what, what that risk management framework ought to look like. All we're saying is that you should have some kind of formalized risk management framework and make that publicly available. Not the decisions, so you don't have to say, we rejected these three apps and we approved these five, but just say, here's how we're approaching it, here are the criteria we're using, maybe something like that.

And the idea is that'll give better information to the users of the system about, how decisions are being made about what's in the system and hopefully will help us all learn. about the best ways to mitigate risk because at the end of the day, we're actually AI optimists at the, here at the department.

We actually think that there's net benefit, but, but we want to make sure that that we're, setting up the appropriate kind of guardrails to make sure that, we're promoting responsible AI as much as possible. I will say, another thing that, that was a concern that we, that we've gotten in the comments was that, is this going to stifle innovation?

Concerns like that, which are, always a concern, obviously, with regulation. It's our observation that there are a lot of physicians and clinicians who are hesitant to use AI enabled tools because of that black box kind of phenomenon. They're worried that, wait a minute, I'm being asked to make decisions based on this thing that no one can really explain to me how it came up with the answer, yet I'm being held accountable for the decisions that get made, right?

At the end of the day, it's very clear that the, you can't say, Oh, I'm not responsible because I use this tool and I don't know how it works, right? That doesn't work in our medical liability. So there's obviously a hesitancy that's starting to develop among clinicians.

And so what we're doing, what we're hoping is that this kind of transparency or, judicious transparency will actually open up the market for innovation and open up the market for vendors in ways that they may not fully appreciate right now. There, there is a

maturity. I actually, I think I saw the Gartner maturity model on AI.

And it was interesting to me because some AI has been around for decades, right? And so when we look at AI around imaging, it is, it's fairly advanced. It's really gotten, but there's other things like we are just. We're so at the beginning of how we're using large language models and, creating notes and those kinds of things that, the, is there some aspect of recognizing in the proposed in the proposal that essentially there, there is different maturity levels of this technology, and this could be trusted a little bit more?

Actually it's, as I'm asking the question I'm hearing the answer, which is there. It's what you're saying is just allow them to be transparent. What is it doing? How is it doing it? Just tell it, just tell the users how it's doing.

I think providing that baseline information that allows the users to start to form their own judgments.

I think that there is a gap in the market right now, which we appreciate that that the users may not. actually have the expertise to evaluate based on that information, which is totally, which is a totally fair point, but I would argue that we have to start with transparency, right?

That's the only way to have users start to educate themselves by making the information available, then they know what they need to educate themselves on. The other area where that might come into play And the other thing that I would say is, I would expect that risk an appropriate risk management framework would take into account the maturity of models as they think about that.

And so that would be something that we would expect that the vendors would also take into account.

how AI is progressing is. very interesting to me. You talk about having a nutrition label and a nutrition label will say, this is how things happen, but you're not talking about having an ingredients label per se, where it says essentially, hey, here's all the things that are in it.

This is the pushback I hear from AI companies. It's hey, that's our intellect. What we trained it on, how we trained it, that's all of our intellectual property. But when you get into healthcare, that specific data set does matter, especially around the whole concept of equity. If I trained it on one data set, it doesn't really apply on the other.

So are we telling people, hey, the data set does matter in healthcare. We do need transparency into

that. Yeah, I guess I'd, have a couple thoughts on that because, we've definitely talked, a lot with those who provided those comments. And again, we totally appreciate, again, I was in the private sector for 20 years before this.

I appreciate the importance of intellectual property and as a driver for innovation. This is not about, saying that Okay. Everything needs to be open source. Everyone needs to, open up every kimono. There's no such thing as intellectual property. That's not what this is about at all. as I think about this, a couple things come to mind. one is that, in the proposed rule, what we propose that the information be made available to the customers. we Did ask the question, should that information be made available to patients as well, which would essentially be saying, made it public, right?

If you make it available to patients, you've made it public. We asked that question. And so now we're considering the responses, but the core proposal that's in the draft rule right now is to just make it available to customers. I would, suggest that those who are saying that they're having to reveal their intellectual property, I would ask them, do you really want to work in the healthcare industry?

Because if you consider that intellectual property that you think that clinicians should not have information about before they're making life and death decisions on patients, then you're probably in the wrong industry. And you should probably just move to another industry where they're willing to take those risks, but we're not willing to take those risks in healthcare, and we're not going to allow second thing I would argue is if you look at those 14 data elements, and I, did a lot of work, I was an advisor to a venture capital firm in my prior life. And so I, totally appreciate the moats that every company wants to create around this technology and around, what it's doing.

I would argue that if those 14 data elements, which are pretty high level. And I, don't want to be snide here, but I would just argue, if that is your moat, you need to dig a bigger moat because that is not intellectual property that is going to make you a unicorn. Yeah, look,

I saw 16 year old kids that are training large language models, and I'm sitting there going, Hey, you know what?

if your intellectual property has to do with something that ChatGPT can spit out today again, that's not a moat. Let me ask you this. You talk about being an optimist and I'm an optimist as well. I believe that there's there's so many technologies that enable us to address health equities, to address access issues, and those kind of things.

I'd love to hear you talk a little bit about how technology, can be leveraged to address health equity issues and and access, especially in the underserved communities.

Yeah, I think that the ability to get a more holistic perspective on the individual. In an appropriate manner that is conscious of the fact that the information that is there is already being generated by a system that has built in inequities.

I think with that recognition as you're building that model, that provides the opportunity to have a much better, more focused experience for individuals who have many different needs as, as we think about. Whether it's, health related social needs or social terms of health or, those kinds of factors that come into play for different types of populations that are more or less prominent for different types of populations.

I think that, the opportunity that AI enabled tools offer to be able to provide more of that nuanced perspective and to direct people to the kinds of resources that are going to best meet them, where they need it is just a great opportunity. And I think that's what these can be very good at.

I think that the danger is that misapplied, either because they're, somewhat naive to the fact that, just remember the data that you're using is already inherently biased because the system that we live in is somewhat biased. So you just have to remember and take that into account by oversampling for underserved communities, for example recognizing that certain decisions that might get made.

actually may be the result of people having fewer resources and not about their clinical decision, not about their clinical condition, for example. I think those are the things that if people are more explicit about that these kinds of tools can offer tremendous opportunity for being able to address some of these needs.

We're going to talk about information blocking in TEFCA in a moment. I do want to ask you about the locus of care seems to be moving outside of the hospitals and we saw Mass General and Best Buy just do an announcement and they're going to the home, Mayo's going to the home.

Actually, a significant number of health systems are exploring what it looks like to deliver care. In the home. Is that a conversation that's happening in at the ONC and at your level of what this change in the locus of care

might mean? Yeah, I think it's happening in a variety of different agencies.

So certainly CMS, obviously, has been looking at hospital home and, and in the payment model that that has supported that come, through the pandemic and coming out of the has allowed a lot of innovation to take place and for us to learn a lot. From that.

So I think, at CMS, at FDA, and at NIH, and thinking about remote diagnostics in test to treat a variety of capabilities that have been a, a part of, what we've been working with those agencies as well, as we think about, how we have More and more ability to have location independent care and thinking about the, the benefits of that and, what capabilities are needed to be in place to be able to support that.

I will say, one of the things that and it's interesting that you pointed to the Mass General Brigham Best Buy relationship. Which speaks to one of the things that, I had looked at for an organization who I had been doing some work for before joining the federal government in this, remote care and hospital home space was that the logistics, the sheer logistics.

aspect of it is actually the most difficult. It's not, people think that, oh, it's, having doctors available on a screen to talk to the patient. That's actually the easiest part of the problem. You can set up a command center at, at a hospital and have ICU, specialists who are, taking care of a lot of patients at scale, through telemonitoring and other kinds of capabilities.

That's relatively easy to set up. The harder things to set up are. How do you get the bed in place? How do you make sure they have broadband connection? How do you make sure the phlebotomist shows up when they need to show up? How do you get the lab, specimen done in time and then the results delivered back?

It was like all of that. How do you get the oxygen there in time when it's needed? That sheer coordination of all of that ends up being the biggest challenge in those kinds of, especially a hospital at home, which has so many different things that, you know, that you need to have in place. And that's

why there's so many limitations on them and why The scope is always very confined within a certain radius of the hospital or the health system.

And then I think I was talking to, to Dr. Hlopka about this and he was talking about Mayo's move in Jacksonville. And one of the things he was saying is they have to go in and look at the home. I think like 35 to 40 percent of the homes aren't candidates. for the services that they would provide in those homes.

And that really gets to the social determinants. Like we don't really know the environment that people are living in. And sometimes that's not conducive for delivering care in that space. And sometimes it's better for them to. literally come out of that space and go

somewhere else.

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📍  we've talked about information blocking, I think, for a long time, you and I actually, let's just start here. wHere are we at today? What are we talking about today versus before, are we at the penalties and disincentives phase?

Are health systems now having to respond to information blocking complaints and those kinds of things? Where are

we at today? Yeah we have been talking about it for a long time, which is a deep source of frustration to me. I will I will note because when I came in none of the information blocking requirements for the 21st Century Cures Act have been put in place and none of the enforcement pieces in particular have been put in place, and indeed one of the trickiest ones, the provider appropriatism incentives, had not even really been scoped out so there was a lot of hard work for us to do.

And, and coming in and just remember, we came in five years after. The 21st Century Cures Act had already been passed. So you just think about, wow, you are really behind the eight ball if you come in, and and you're already five years have passed and you don't have a whole lot to show for when, how do we get this policy fully in place.

But that said we, made the effective date on April 5th, 2021. So then, that started the clock ticking to say, all right, information blocking is now a requirement. But the other pieces of the puzzle that still weren't in place, but are now almost fully in place, were one, enforcement.

So the information blocking rule, basically has ONC defining the policy. And then our partners our agency partner, the Office of the Inspector General, was given the authority to do the enforcement side. So they would do, based on complaints that come into the ONC portal, they would decide what to investigate.

And then they would determine whether that particular actor is is found to be not in compliance, and then would work through, a set of penalties for that. And that was not in place, yet either, but that rule that was a separate rule from the Office of the Inspector General, was finalized in the summer, I think it was July of this this year, and enforcement went into effect starting September 1st.

That piece of the puzzle is now there, and now in place, OIG is, has notified the industry that, that enforcement has begun as of September 1st. The remaining piece was the appropriatist incentives or penalties. That might accrue to a provider who is found to be not in compliance with the Information Blocking Regulation.

I think as you and I have discussed before, the statute, the 21st Century Cures Act, defined penalties for health information networks. And for EHR developers, certified technology developers, which is mainly EHR developers who were found to be not in compliance. It gave new authorities for that to the Office of the Inspector General.

It defined penalties, civil monetary penalties. Putting that into rule is relatively easy because it's great, we were handed this new set of authorities from the Congress. Now we just need to write a set of rules implementing them. Unfortunately, for the providers, what the statute did is it said that the Secretary of Defense not Defense the Secretary of Health and Human Services will be responsible for defining appropriate disincentives.

So they didn't even define it. They just said the Secretary of Health and Human Services will define it and the Secretary needs to use existing authorities. and do it through notice and comment rulemaking. So that really puts it into, quite a box there because you're basically saying, all right, so I've got this new policy, but I'm only allowed to use existing authorities to be able to do that.

And that's a much harder exercise to go through. So anyway, so that's what, we've spent, just over two years working really hard on, developing the regulatory framework. For, how would you approach that in the first set of potential disincentives that would apply to providers who were found to be in non compliance.

And so we're really happy that we're able to issue the draft rule of that in October. So that starts filling in that last piece of the puzzle. You've got the enforcement piece and you just have this remaining piece about the physician penalties, the draft rules in place, we're getting comments on that now, then we'll go through the finalization of that, and then that'll be finalized, and then you'll have, the first, the full set of information blocking policies fully in rule.

I will just note, and the Secretary said this in the press release, is that, we anticipate that this is the first set. of penalties that there, will, as we continue looking at it there could very well be additional types of penalties that that we will invoke as a part of the regulatory framework.

But it was important to just get the framework out there and to get the first set of disincentives out there. I know that in

other areas, we're looking at the payer data. Are we considering the payer data for this kind of thing, or is that just so after the fact it's not relevant?

So maybe I'll speak out of school here.

Payers were not included as actors in information blocking, and that's in the 21st Century Cures Act. So there's nothing that we can do to include them. I will say as an aside, personal comment, this is not an official ONC position. My personal comment is I absolutely would have included payers as actors in information blocking.

Their information is It's just as important to the healthcare industry and to patients as the clinical data. And but they were not included. So the fact that, sometimes we get complaints because we've we get roughly five complaints a week. If you look at the data that we post on our websites, we get roughly five complaints a week.

The vast majority of the complaints are from patients alleging information blocking by providers. Sometimes we do get complaints. that are against payers, and we'll have to screen those out. We do contact the submitter and just, and just tell them, you know what, this technically isn't information blocking because payers are not actors in information blocking.

Although we might look at it and say, Boy, if that was a provider, that really looks like it might be information blocking. But because it's a payer, we have to, we have to say, no, that's not

information blocking. So before we move on to TEFCA, I think there's some interesting movement on TEFCA coming up.

Let's tie all this back. 21st century cures. Let's tie it back to the patient. How are these new rules around information blocking? How are they going to improve patient care and impact the patient's

experience. So we're already seeing it impact the patient experience. So it certainly opens up access to patients for their own information and that access.

Has a couple of different dimensions. One, it broadens the scope of the information that should be made available to them electronically. HIPAA gives them a right of access, so this doesn't change that. They still have a right of access to the, to the same information that HIPAA gave them a right of access to.

But what the information blocking does is it kind of complements what HIPAA says and says that if it's electronically in your system, you need to make it available electronically. Unless you have a really good reason to not make it available electronically. HIPAA doesn't really speak to that directly in that manner.

The first thing is that patients should, over time, start to see that more and more of their information is available electronically. Not just the window that they have right now in their patient portal. Which is great. I'm not, certainly don't want to criticize that because that's all driven by ONC regulation, and we're proud of, what that's accomplished.

But there's a lot more information in a medical record system that patients have a right of access to that they don't really have good access to electronically. So that's the first thing is it broadens it. The second is that it, modernizes the availability of it in ways that, you know that we've been accustomed, become accustomed to in other parts of our way, our life.

Like real time access. To that information. So I think what, one of the things that we've heard most about, and certainly the patients have experienced, is that they have almost immediate access to their results, like lab results, for example, and diagnostic results which is a part.

that wasn't the only policy from the information blocking regulations, but is one of the aspects of, of how the information blocking regulations affect the way that information is made available. And, we've gotten lots of feedback.

from providers and from patients about the the regulation. overall, the industry seems to be adjusting that it was, definitely a change especially for organizations that, that perhaps didn't implement it quite as well, meaning that they just turned on immediate results delivery without training their staff.

So the, Poor people on the front lines were the ones who were taking the calls about, Hey, wait a minute, and it was like wait a minute. Couldn't you have trained, your front line staff before, before doing that to them? Now the industry is adjusting, I think. And overall, I think we're seeing that there's, strong patient sentiment based on actual research that's been done, like by Vandermilt and other places, showing that patients by and large do appreciate getting their results immediately, even if it's bad news.

Even if it's bad news and and there's additional functionality that certain vendors are, putting into place that allows a patient, like my provider, for example, the EHR they use on the patient portal, I can actually check and say, I do not want to receive these lab results until my physician. had a chance to review them and talk to me about them. That's a choice that I have now which I would argue that's the world we want to live in, right? People ought to be able to have the choice, whereas the world we lived in before, if you did want your results right away, you didn't have a choice, right?

Everyone had to wait. for the most conservative patient who, you know, who didn't want that. That's what drove everyone's access. This way we're saying, the system ought to meet patients where they want to be. And it turns out that a large fraction of patients want to get their results right away.

And, that's an implication of the rule. The other part that is that it ought to open up. Sharing among providers as well as with payers and with other authorized entities. And, we're starting to see, the first glimmers of that as you start to hear experiences of providers with each other, asking questions about, is this information blocking?

This seems to be information that I ought to be authorized to get. And, and policies that I think are slowly changing in provider organizations to make more of that information available. I had

a great conversation with a set of doctors when I was a CIO. And we were talking about all this grandiose stuff.

And I said, would be the number one thing that would impact health? And one of the doctors said, engage patients. Just flat out, period. I don't care what technology you're doing or whatever. It's engaged patients. He said, because, the number that don't take their medications, the number that just aren't engaged in their health, because anything you can do in that area to keep people involved,

engaged in

their own health, that is going to go a long way.

And I still remember that conversation, because as I think through these conversations around technology and other things, it's always around. Okay. That's great. We're getting this information, but why are we getting it to them? It's so that they stay involved, so that they know we trust them with their health.

We trust them with the information. We trust them. It's almost the same thing around transparency with clinicians. It's hey, we can give this information to the clinicians. They are smart enough to understand it. And a lot of them. will utilize the technology if they know what it's actually doing.

I Totally agree. And there's a, there's a story. I'm not at liberty to share the individual's name because they have told the story, but I think they're not widely publicizing it. But it's an individual who is Very familiar with clinical informatics and as a clinician themselves, and they've they have a rare type of cancer that emerged, and they had to have some very delicate surgery to address that cancer, and they're in a health system and this will tie together a number of the threads that we've talked about actually, and this is recent, this is like in the last six months they tell the story of being able to get electronic access to all of their records that even as a clinician, they may not have been able to get, but being able to literally get the operative, their operating notes the surgeon's notes, all of the notes, everything, they were able to get it electronically.

Exactly. It was some work, but the information blocking rule enabled them to wrench that out of the system. And then they took that and they ran it through CHAT GPT and basically said, what do you see here? was this following clinical guidelines? Does the information suggest that the diagnosis of this, it turned out to be a very rare form of cancer that seems to be robust?

And they were really surprised at what they got back. That it was actually really good, just from the generic chat GPT. It wasn't, a focused or hyper tuned model. It was just the generic chat GPT what they got back, it pointed out the reasons that the diagnosis appeared to be solid.

It also pointed out gaps in the operating notes that suggested that it looks like they did margins at 270 degrees. around the tumor. Why, you might ask, why didn't they do a 360 like that. And then this person brought it back to the surgeons and said, here's what CHAT CPT said. and they and by this person's accounting, the surgeons were like, those are fair questions to ask.

And then here are the reasons why. And they were all legitimate reasons. There wasn't, there weren't mistakes made, but the whole experience, I think pointed to there is a level of computer, engagement here that could happen. Obviously, right now, it's going to be for the very lead adopters.

This person's obviously very sophisticated, but the highly lead adopters, but as we've seen with any innovation cycle, it's always the lead adopters, and then that starts to, get commoditized and work its way into the big, the majority adopters. And and I think that's just the tip of what we're going to see in the future.

right, so we're going to bring this to a close. We're going to talk TEFCA and public health modernization. are the two things I want to close on. TEFCA, by the time people are listening to this, it's going to be in January. if I'm not mistaken it becomes operational next year.

what can people expect? What's the most significant changes we can expect in health information exchange as a result of TEFCA?

Yeah I hate to undersell what we're doing or burst anyone's bubble. The world isn't going to look different in January than it looks in December.

So let's just make that clear. But it is going live in next week, actually. And what that means is that a group of networks that'll be announced next week will be fully approved and will have implemented their infrastructure to be able to conduct transactions under the TEFCA framework.

What that's going to mean, I think, over the coming year, and then certainly the following years, but even over the coming year, is that we should see a lot of, the replication of the kinds of interoperability that happens today. So it's not as if, a lot of that new stuff will happen, but we'll start to see more of the newer use cases that the private sector has had a hard time getting to in in the current network interoperability world.

For example, public health agencies. We're working with public health agencies to have first production, hopefully in 2024, of a number of public health agencies who will be able to just use network services to be able to receive information that they now get in very kludgy ways and point to point interfaces to be able to say why can't we just do that using modern network technology and the opportunity and ability for them to share information with each other.

So that'll be a big breakthrough that again, for most individuals, that's really behind the scenes, but providers care a lot about it. Because public health reporting is really hard for them right now, and hopefully public health agencies will start to appreciate the benefits of network interoperability that they'll start to see there.

Another area that, you know, that we're really excited about is that we'll start to see payers being able to participate. in health information exchange. And, the importance of that is that we'll, I'll start to see availability of information for providers and payers that allows them to have the best available information to be able to provide the best best type of care or services to patients, whether it's about claims data or clinical data.

That'll be an innovation that, the TAFCA will spearhead to start making that information available. And then finally, we individual access. ought to get better. It won't be solved overnight but, through the TEFCA framework as in the go live of FHIR based capabilities, which will happen in 2024.

The ability for a patient to be able to use a single application to be able to get their information from multiple different places, which they can do today with certain applications, but it's still pretty hard. That ought to be made a lot easier. And then, and hopefully individuals will start to notice that for those those who want to be able to do that.

core data set? How is that evolving? What are we starting with and what do we anticipate?

Yeah, I think the basic information that will be exchanged will be the U. S. CDI, the U. S. core data for interoperability, which is that minimum data set. That ONC requires be made available in certified electronic health record systems.

And it's the, the basic payload of networks today. But in TEFCA, we don't limit it to that. We actually, technically say that the information that's required is all electronic information. Electronic health information. But, but we also recognize that there aren't good standards for a lot of that other information.

So what we do is we basically say, we expect that you're going to exchange that U. S. CDI, but you are welcome to exchange anything on top of that. And the capabilities within Tefco are there. The plumbing is there for you to be able to exchange all of that. And we just hope that will start to grow over time, certainly encouraged by the information blocking regulations, which require the availability.

of that, all of that other electronic information. So as people start to wrap their heads around complying with the information blocking rule, they may start to see that, you know what, TEFCA is the way for me to do that. If I just start to make more information available via TEFCA, then I will have met my information blocking requirements for many of the cases that could possibly come.

Public health modernization, I think the pandemic was a Tide going out kind of event for the public health infrastructure and, things we didn't know, now all of a sudden became,

Headline. Yeah, we saw a lot of people didn't have bathing suits on. Yeah,

it's very interesting.

And I remember talking to health systems are like, the state's requiring me to send this information and they have no way to receive it. or we're overloading their system or fill in the blank. How will. Hopefully it won't happen in our lifetime, but who knows. How would the next pandemic look different with TEFCA in place?

will it ease some of that? Yeah, I think it will and in a couple of ways. So one is that Tefka is in theory, because you've got very high performing networks that could only become QHINs if they were high performing, they had to demonstrate that they were able to conduct millions and millions of transactions a day and that they have the infrastructure and the business sophistication and the technical expertise and the governance to do that.

So in theory the network itself will be infinitely extensible. It won't crash because of volume, at least as from transport perspective. And that was a big problem that we saw during the pandemic was literally, the interfaces couldn't support the volume of data, let alone being able to actually consume the data once you've received it on the other end of the pipe and, and process that data.

At least, from that perspective, we'll have that. The ability to have an electronic directory to know where I want to be able to get information and to actually query for that information as opposed to just have it be pushed to you in static reports on some timeline that may or may not meet the need of the moment I think is another capability that TEFCA offers.

So a public health agency, for example, if it wants to be able to do case management and it actually gets a report that says that a patient may have COVID, may have the next generation of COVID, whatever that patient been seen. Do a record location, and then what's the electronic the phone directory, the endpoints of those provider organizations, and then let me do a query for very selected information that will help me identify whether that patient actually does have this pathogen, and then be able to reach out to the provider to be able to, figure out what to do about that.

None of that capability exists today, Right now we do it via fax. Phone calling all of that, falls down anytime you, really pressure test it. The last thing that I would point to that TEFCA will enable is for jurisdictions to use commodity secure network services to communicate with each other.

Think about, Texas, Oklahoma, and Arkansas. A lot of people go across those steep lines, and as it exists today, and this isn't a criticism of Texas, Oklahoma, and and Arkansas. It's any three states in the country. They don't have the ability to securely exchange information with each other in real time. have an ability to exchange information in real time. It's called a telephone. That's how they do it, right? They do it via telephone, email, fax. And all of the inefficiencies and errors that, system has embedded in it, but the ability for us to be able to say, you know what, let's assume that no one's made any commitments, but if Texas, Oklahoma, and Arkansas are TEFCA participants, they could exchange information with each other as per what their state and local authorities allow them to do in much more, secure and real time ways and scalable ways than they're able to today.

Well, Mickey,

I'm really in awe. You still seem to still have the passion. Now you went in and you're still very passionate about

all these topics and I don't, I haven't lost the energy yet. I've

read some of the comments and that, there's a lot of very difficult, challenging things to get through and a lot of difficult conversations to have.

you, you seem to still be very passionate about moving these things forward. And I appreciate someone like you being there who has been on both sides. I've been on a lot of sides. Actually, there's not both sides, but on a lot of different sides this equation with health systems, with HIEs and other things and seeing the history of it and still be passionate and moving it forward.

I really appreciate the work that you and the teams

That are doing to this, when I came into healthcare, I could not believe that we couldn't share the information across the street. And people might not remember that and they might look at today and say, have we really made progress?

We really have made. A lot of progress and it's due to a lot of the work that you and your team are doing and I appreciate that. Thanks,

Bill. I really appreciate your comments. And I'll say, my enthusiasm comes from, how privileged I feel to be able to work in a mission oriented organization and for mission oriented leadership and a mission oriented administration.

So we're really excited about, everything that we're working with stakeholders on.

MiCkey, I'm sure I will see you throughout the year and look forward to the next time you're on the show. Thank you very

much. Likewise. Thanks, Bill.   📍   📍 I love the chance to have these conversations. I think If I were a CIO today, I would have every team member listen to a show like this one. I believe it's conference level value every week. If you wanna support this week health, tell someone about our channels that would really benefit us. We have a mission of getting our content into as many hands as possible, and if you're listening to it, hopefully you find value and if you could tell somebody else about it, it helps us to achieve our mission. We have two channels. We have the conference channel, which you're listening. And this week, health Newsroom. Check them out today. You can find them wherever you listen to podcasts. Apple, Google, overcast. You get the picture. We are everywhere. We wanna thank our keynote partners, CDW, Rubrik, Sectra and Trellix, who invest in 📍 our mission to develop the next generation of health leaders. Thanks for listening. That's all for now.

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