Ready, Aim, FHIR: The Future of Interoperability


Editor’s note: Cambia Grove is proud to partner with the innovation community to amplify their perspectives on topics applicable to the larger health care ecosystem. This blog post from Ed Butler, our Washington State Innovation Council member and Vice President of Corporate Development at Keya Medical, recaps Advancing Data Interoperability: A discussion with Micky Tripathi. If you missed the event, here is a link to the recording.


I’ve heard Dr. Micky Tripathi speak before and was glad to have the opportunity to hear his take on a series of questions from the panel of 2021 Cambia Grove Innovator Fellows. Dr. Tripathi heads the Office of the National Coordinator (ONC), the principal federal entity responsible for coordinating nationwide efforts to implement and use advanced health information technology and standards-based health data exchange. Dr. Tripathi is the eighth individual to hold this office, created in 2004, and the seventh National Coordinator I have had the opportunity to hear speak. His immediate predecessor, Dr. Don Rucker, spoke at Cambia Grove in 2019. Of all the ONC leaders I have followed, Dr. Tripathi probably has the most in-depth experience as a data standards developer, which is why his candid perspectives are especially useful. In this post I summarize three insights I drew from this discussion:

1. Health data interoperability is unpredictable

It was refreshing to hear an acknowledgement that the road to health care interoperability is not a deterministic, linear roadmap. Dr. Tripathi observed that “what we've learned from the Internet economy over the last 30-40 years is that the availability of information is what fuels growth and innovation.”  He noted that 

information flow helps us grow in ways that are unpredictable and that, to me, is one of the most important things about it.

He emphasized that we need to be able to get more “authorized eyeballs” on data and information so that innovation can unfold. This openness to standards-grounded innovation reflects a wisdom in a vision that recognizes its limits.  

2. Reframing Supply and Demand

Like his predecessor Dr. Don Rucker in 2019, Dr. Tripathi brought up market forces of supply and demand, but in a completely unusual way. He applied the term “supply side” to government regulations and standards in response to panelist questions about the transition to value-based care from fee-for-service, the usability of Electronic Health Record systems and the digital divide between rural health systems and those with advanced EHRs. Dr. Tripathi observed that as a government official “you have to know what your authorities are.” For example, he said “ONC has very specific authorities related to certification of electronic health record systems and technology enablement. I think of it as the supply side of health.” One example he gave of the power of ONC to create opportunities for innovation is the United States Core Data for Interoperability (USCDI). The USCDI standard is required as part of the new application programming interface (API) certification requirement for Electronic Health Record systems.  He pointed out that “the US core data for interoperability is kind of the minimum data set. Whatever design you have, whatever you're doing, you should start with the USCDI and build from there.”   

Contrasted with the supply side is the demand side. Dr. Rachel Gerson, a practicing diagnostic radiologist and Keya Medical advisor, posed the question about re-envisioning interoperability to improve outcomes for patients and better support the work of clinicians and researchers. Dr. Tripathi’s response was provocative and direct:

Part of the problem here is that health care institutions, individuals within health care institutions, don't demand interoperability like they demand other things. They demand to get paid.

He suggested that we look at the entire ecosystem. “The biggest driver of interoperability is value-based care,” Dr Tripathi asserted, “I’ve seen so many organizations almost overnight flip their perspective” when signing a value-based contract “and the next day it’s ‘where is my interoperability?’” 

In short, Dr. Tripathi is suggesting that the answer to insufficient vendor offerings is not easily solved by government regulations (supply side) but must be driven by customer demand and the shift to value-based care. He observed that EHRs are a platform, and customers should not have to wait years for the EHR vendor roadmap to solve issues they could solve sooner by plugging in a standards-based third party application. However, gaining market access for such apps is non-trivial. Dr Tripathi compared the battles that are going on with the Apple App Store with the challenges of having a competitive and open innovative marketplace within the EHR platforms. 

3. It takes a community—and time

Dr. Tripathi was an early leader in the movement to create the Health Level Seven® (HL7®) Fast Health Interoperability Resources® (FHIR®), which were based on open APIs modeled on modern software development patterns such as REST. These describe how individual packets of information (resources) can be shared easily without regard to how they are stored in their source systems. The ONC regulations already require HL7 FHIR interfaces to EHRs; however, the implementation date has been postponed until the end of 2022. 

Dr. Tripathi pointed out that open industry standards go through standards development organizations, which are driven by volunteers, and this becomes a constraint on how fast the process can go.  This is not a bad thing, he noted, to balance speed of standards development with open industry processes.  He contrasted the current HL7 FHIR community approach with lessons learned from standards driven primarily by academic informaticians. “You have to have people who really have a good domain sense of how this is going to work in real life.”  He added 

And I think it's important that anybody who's listening to this webinar knows that they are welcome to come roll up their sleeves and join in to bring their expertise. And we need people from all portions of the health care continuum.

The context of this discussion fell within Cambia Grove’s Innovator Fellowship program in partnership with the HL7 FHIR Accelerator™ Program. This year's ’Fellows are building a value metrics framework scaffolded by interviews with interoperability subject matter experts including the Argonaut ProjectCARIN AllianceCodeXDa Vinci ProjectGravity Project and Vulcan. The final report on the value open data exchange brings to health care organizations will be presented at the finale event on October 21; learn more and sign up for the event today.


About Ed Butler

Ed Butler is Vice President of Corporate Development at Keya Medical. He has worked with health data interoperability issues for 30 years within payers, hospitals, physician groups, EHR vendors, and standards development organizations. He is a past co-chair of the ASC X12 Eligibility Work Group and a past recipient of HL7’s Volunteer of the Year award.



*The views expressed in this article are solely those of the author and do not necessarily reflect the opinions or positions of Cambia, Cambia Grove, or any other entity or organization.*