National Coordinator Donald Rucker, M.D. Assesses Progress Towards Interoperability and the Development of Open APIs
Donald Rucker, M.D., who was named National Coordinator for Health IT in the spring of 2017, has been focusing his tenure as National Coordinator on a handful of top policy priorities for the Trump administration, among them, interoperability across the U.S. healthcare system, via, among other elements, the Trusted Exchange Framework and Common Agreement (TEFCA), and the overall 21st Century Cures Act of 2016, out of which TEFCA emerged; and reducing the administrative burden on physicians and other providers, as articulated in recent speeches at major healthcare conferences by Alex Azar, Secretary of Health and Human Services, and Seema Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS).
Dr. Rucker continues to speak at all the major industry conferences at which national health IT leaders gather, including at the annual HIMSS Conference. And he recently spoke with Healthcare Informatics Editor-in-Chief Mark Hagland to talk about his current efforts, and how he sees industry evolution towards greater interoperability and healthcare system transformation. Below are excerpts from that interview.
What are the main areas you’ve been working on recently, Dr. Rucker?
We’re still working on the things that I’ve talked about publicly—the rulemaking in process on open APIs, information-blocking, TEFCA; and we’re sorting out what we can do on burden reduction. We’re still pretty much working on the exact same things that we had been working on before.
Donald Rucker, M.D.
What are you putting the most energy into right now?
Obviously, an aggregate 21st-Century Cures has a number of specific provisions. By law, we have to work on all of them, and by law and federal rulemaking processes, they’re sort of going to come out together. That’s in the list of upcoming rules. So they sort of come out as a pack; and they all feed off each other on some level; some feed off each other directly. The focus on open APIs, and preventing information-blocking, sort of mutually reinforce each other. And clearly, that was the explicit intent of Congress. The broader intent, probably of the prior administration and certainly of this administration, is for us to get more for what we pay for in healthcare. It’s no secret that we’re not getting a good deal in American healthcare. And certainly, that idea picked up a lot of steam with Don Berwick and the IHI [Donald M. Berwick, M.D., the former CMS Administrator and the president emeritus of and a senior fellow at, the Cambridge, Mass.-based Institute for Healthcare Improvement], and similar efforts. And, I’m not a pollster, but I’m told that’s a major issue in voters’ minds. All of us are seeing our prices rising, as consumers.
And with all of that going on, one of the big opportunities, I think, and the White House thinks—Jared Kushner in the Office of American Innovation, and Secretary Azar and Administrator Verma, all think, and certainly I do as an IT person—everybody sees that IT is one of the potential keys to the kingdom, in terms of rethinking business models, and achieving accountability. Right now, as a provider, there is no broad-based, computational capability around what you do. You may have to provide a narrowly scoped set of quality measures; and private payers may ask for some specific data downloads; but there’s no clear interoperability standard to look at the overall performance of providers, with any of the modern computer science tools we hear about—AI, machine learning, big data. You can talk about big data all you want, but if there’s no computational interface, it remains limited, often right now to individual providers. Ultimately, we’ll need to get data out from all providers simultaneously, to be able to shop intelligently for care, identify disease outbreak threat vectors, etc. So those are some of the things the senior federal healthcare officials are thinking about.
Secretary Azar spoke about hospital pricing transparency, and the potential for direct physician contracting, in his keynote address at the World Health Care Congress at the beginning of this month. And he and Administrator Verma both spoke of the freeing of data to support the new healthcare, particularly to support healthcare consumers.
Yes, and as part of the search for value and empowering consumers to shop for their care, clearly, it’s very hard to shop for anything if you don’t know the costs. There’s a broader desire to empower patients with information, whether it’s through Blue Button 2.0 or anything else. And as I understand it, at CMS, they already use Chargemasters to build up their cost baskets; so there is data already in the public process. So this information is there. And what the CMS news release said is that they want to make this information that’s already on the public record, electronically actionable. It’s one thing to make something ‘available,’ and another thing to make it easily accessible. There are a number of [vendor] companies that are working on price transparency; and the assumption is that they or other groups would combine this with other consumer information. Who will end up doing this or succeeding with this, is to be determined. You’re starting to see some of the major payers explore the world of apps, and fronting those directly to their insureds. So that’s going to be part of the fabric of price transparency.
Physicians will say they don’t have the IT infrastructure to take on direct contracting right now. Do you see that as a potential challenge to direct contracting?
Adam Boehler, the new head of CMMI [the Center for Medicare and Medicaid Innovation] is a very smart guy. My guess is that there will be a lot of things going on. Secretary Azar is bringing on experts in some of these various pricing areas; it’s an ongoing thing. I don’t have any comments on specific payment models. But it’s certainly embedded in the design of CMMI.
Would you agree that physicians will have to step up pretty quickly in terms of upgrading their IT capabilities, in order to participate in the new healthcare? Many feel they simply are not in a position to be fully capable, in terms of their IT infrastructure, of participating in some of the activities they’ll be required to participate in going forward.
It’s an interesting question, and I’m going to put on my MBA hat here. It’s a very interesting question what the natural scale of the business is or should be. Right now, it varies from solo practitioners to dominant IDNs who are hiring primary care docs, right? That’s a pretty broad range of scale. And it sets healthcare apart from many other industries. So I think we really know the range of optimum scaling factors here; part of what determines the optimum can be IT, but, very big caveat here, that does not mean that it needs to be a big enterprise software system, right? It may just need to be on the cloud. Uber and Lyft have massive IT infrastructures, but that doesn’t mean that individual drivers need massive infrastructures. So there’s no simple answer to that question, because I think that the IT can scale to different levels. Now, as a practical matter, in the U.S., various favored layers of scale have probably been created by the government or market, by implication.
When you look at the current trajectory of the development of open APIs, would you say that that development is not moving fast enough? How do you see it?
I think you need to focus on one key element, the phrase “without special effort,” in the Cures Act. The language says, not, just open APIs, but “open APIs without special effort.” I can write code and expose my function wall to the world, and call it an open API. And while it is technically open in that I haven’t locked it down, it’s not really usable. If somebody wants to use it, what data is even behind there? Why would I do it? It has no component of operational transparency. So you could imagine that kind of strategy maybe working for one or two of the largest vendors, but it doesn’t have public good to it.
“Without specific effort” means you must use industry standards that allow ordinary developers to access your technology, using normal tools. There are a bunch of interop tools, such as IHE, DICOM, etc.; but when you look on a go-forward basis, and this is clearly tied to consumer sovereignty of getting their chart on a smartphone—Cures says, “open API without special effort.”
So ONC has to figure out, OK, what does that mean, in a rule? How do we determine which APIs meet that criterion? The open API without special effort, when you think about the app world—every app that you have that uses mapping tools, like Google Maps, they’re using a technology called RESTful [the representational state transfer architectural style]. And if you look really fast, you can get the outbound string, but you’ll mostly now see the prettified URL. That API of the app economy is what we want to bring into healthcare. That API has three major components, besides connectivity to the Internet. They’re using the RESTful gets and puts; the data standard, typically JSON [JavaScript Object Notation open-standard file format], a really simple way of representing data; and then, to get these data structures into the language of healthcare, FHIR resources are put on top of that. That’s the modern stack. It’s sort of hard to come up with anything besides that to meet that criterion. So we’re sorting out how best to say that.
In terms of development, there are already small companies using that. There was The Argonaut Project that put the implementation guide together. And you saw a couple of months ago Apple announcing that they’re using the FHIR stack to fuel their health app. There was a very nerdy article on machine learning and neural networks written by 30 authors from Google, UCSF, Stanford, and the University of Chicago recently [“Opportunities and obstacles for deep learning in biology and medicine,” Travers Ching et al, Journal of the Royal Society Interface, published online April 4, 2018], and they were using neural networks using hundreds of thousands of data fields per patient, and representing all of that as FHIR. So I would submit that the first step across the dance floor has been taken. We just heard from someone who said that the morning after Apple made that announcement, probably 300 hospital CIOs were called into their CEOs’ offices to ask what they were doing. Who knows how many it really was? But I think people get it. They obviously know something’s going on. So I think some of this progress may be so fast that it will be even faster than the timelines that we embed in rulemaking.
The recent announcements from ONC and HHS indicate that you’ve moved on from meaningful use—am I correct?
The program has morphed. And again, the meaningful use stuff is a CMS construct rather than an ONC construct, just to be clear. ONC does the certification; CMS incorporates certified EHRs [electronic health records] into their rulemaking, but sets all of the parameters around MU. It’s no secret that the big focus of this is now promoting interoperability. Clearly, we’re trying to reduce some of these burdens. Congress, in the [continuing resolution funding the federal government that was passed in February of this year], passed a rider saying there didn’t need to be an ongoing escalation of certification requirements. And the line in the HITECH Act saying essentially that each version had to be more or less more stringent—I’m not sure the precise wording—was eliminated in the last go-around of budget development, as a line item. So you’ll see a focus on promoting interoperability. Now, the certification act, the HITECH Act, is still there; but our go-forward focus is really on interoperability for patient empowerment, price transparency.
Is there anything you’d like to add?
In the discussions around transparency, it’s also important to understand that we need transparency into the services provided. Transparency is a broad narrative. There’s price transparency, there’s transparency into what was provided. And this same transparency can help with markets lower cost, help develop a learning healthcare system. And at the center of all that, is open APIs.
