One of the biggest obstacles to streamlining information sharing in the health field, is the data itself. For decades, various health information systems decades simply have not been compatible with one another. That makes things slower and less efficient for patients, health care practitioners, and the industry itself. Recently Health and Human Services (HHS) updated something known as TEFCA,  the trusted exchange framework and common agreement. TEFCA is all about interoperability of health information. For the details, the Federal Drive with Tom Temin  spoke with Dr. Micky Tripathi, the National Coordinator for Health Information Technology at HHS.

Interview Transcript: 

Tom Temin And there seem to be two parallel efforts that have been going on for some time. One is about the data. One is about getting more institutions to use electronic health records, which has been partially successful. But tell us more about TEFCA what it is and what’s going on with it.

Micky Tripathi So let’s just break that down a little bit. First about getting people to use electronic health record systems. We’ve actually had remarkable success over the last decade. So owing to a lot of federal support in the way of incentives to provide organizations, as well as a lot of private contribution and sweat equity from physicians and those adopting systems. Now, 97% of hospitals and about 80% of physician offices across the country use a certified electronic health record. So not just any old electronic health record system, but they use an electronic health record systems that certified by my office, the national coordinators office. So we don’t actually have a big problem with respect to adoption of electronic health records among hospitals and physician offices. We’ve done a tremendous amount of work over a dozen years on the public and private side to get that in place. But what we’re trying to do now is make it as easy as possible for those systems to share information with each other in the best interest of patient care.

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Tom Temin Got it. And that’s where the data interoperability piece comes in. And so TEFCA is all about the data. Fair to say?

Micky Tripathi It’s all about sharing data among those systems in a safe, reliable, accurate, privacy protecting way.

Tom Temin Is the challenge there for getting the systems to maybe update or alter in such a way that the data becomes more interoperable. That is to say, if your gastroenterologist has one system and your eye doctor has another, why those two would ever need the mix, I don’t know. But the idea is that one practitioner could see what’s going on with another again, at the micro level. And also, I guess for the research community, having interoperable data from multiple sources of systems would be really important.

Micky Tripathi Yeah. And certainly one part of it is making sure that the data is sort of compatible, so that if I get information from another practice from another provider, that I actually can make use of it and not have to go through all sorts of expense and heroic efforts on my side to figure out what that data is, because the minute you do that, we know that people will do what everyone does and that you and I do in our regular lives, which is, well, I got it electronically, but it’s too hard to figure out. So just send me a fax or let me just pick up the call or can you just mail it to me, it’s a lot easier. So what do you need to do is say, how do you make this electronic mode easier for people than the existing ways of doing it? So one part is the data itself, and I’m happy to report that’s a big part of what we’ve done with the electronic health records. So as a part of those electronic health records that, as I said, cover the vast majority of hospitals and most physician offices, they’re required to support a minimum data set standard that we call the U.S. Core Data for Interoperability, U.S CDI. And that’s like a minimum data set that standardized data that covers all of the data, mostly that you woud think of, Tom, even though I assume you’re not a physician. But if you were off the top of your head going to say, what information do I think my doctor would want to have? Well, it’s your problems, your allergies, your medications, your lab reports, your results of imaging. That’s what’s in that dataset. So that we’ve been able to accomplish. It’s absolutely not perfect, but there’s a lot of commonality there. So if you’re a Nome, Alaska, or in Sarasota, Florida, you can have a pretty good expectation that the data you’re going to get out of an EHR system is roughly compatible. Again, not perfect, but pretty good.

Micky Tripathi The challenge is how do you connect up those systems, so that when I ask you for a record for, let’s say electronically, that I know you are who you claim to be? How do I know that you’re not Joe’s hacking shop trying to hack into medical records and then sell them on the dark web. And that you’re actually authorized to have that information. So there’s a difference between saying, well, you are a physician office, but how do I know that you actually see that patient? Because if I give that information to you and you actually don’t have a treatment relationship with that patient, that’s a violation of privacy from an ethical perspective, it also could be a violation of law as it relates nationally as well as state. So that’s what these networks do is provide that overlay of governance and technical and policy requirements that give everyone assurance that everyone on this network is a responsible actor, and if they don’t act responsibly there’ll be penalties and sanctions associated with it.

Tom Temin We are speaking with Dr. Micky Tripathy. He is national coordinator for health information technology at the Department of Health and Human Services. And who are the parties to TEFCA? I imagine the federal government is more of a convener, but also a party to it.

Micky Tripathi Yeah. And I think you said that right. The federal government is a convener right now. So the direction that we got from the 21st Century Cures Act of 2016 was for ONC, my office, Office of the National Coordinator to help to develop a nationwide network of networks interoperability model. And what that means is why do we say network of networks? The analogy I like to use is think about the way cell phone networks or ATM networks for that matter, work today in the market. Let’s take cell phones because everyone’s very familiar with those. You’ve got AT&T and Verizon and T-Mobile and Sprint, and all of those are actually private networks. If you think about it, they’re private commercial networks, but they are connected on the back end via network like governance, technical specifications, expectations about how they exchange information in a way that you and I have the experience of it being a single network. We don’t worry about, well, Tom, you bought AT&T phone. I bought a Verizon phone. We’re not gonna be able to talk with each other. We never worry about that. We go to Best Buy and we buy or go wherever you go, and you buy the cheapest, best phone for your needs. And you know what’s going to be connected with everything else. Right now in health care, we have hundreds of networks, literally. Some of them are state and local networks. Some of them are nationwide networks, but they really don’t connect with each other. And what we want to be able to do, and the direction we got from Congress was basically not deploy boards in their mouth, but basically say do for these clinical networks, what cell phone networks have today that you purchase the system you want, you join the network you want, and you’ll have the assurance that you will be safely connected to every other network. And you don’t need to worry about that anymore.

Tom Temin And is the network technically encrypted or VPN type of version traveling over the internet, or are there actual still networks like we used to have value out of networks that predated the internet?

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Micky Tripathi Yeah these are, in the sort of in the modern age, though, everyone has commodity internet. So basically a network is about establishing governance and then establishing security protocols and  technical infrastructure like public key infrastructure, for example, to define what is the network, if you’re a part of that, that PKI infrastructure using X509 certs and all of that regular infrastructure, then you are now a part of our network and there are rules about who’s in and who’s out and what are the rules of the road. We’re not laying down T1, T3 lines anymore. We can just use the commodity internet, but there is a security overlay. So only those who are a part of the network can actually exchange information with each other within the same way that your banking information is highly protected, even though you’re using commodity internet. There’s no special line between you and the bank. You’ve just got additional security provisions on top. We use the same set of security protocols for TEFCA, this kind of network exchange as well. But the networks again, it’s network of network. The networks are already established networks. I mean, that’s the principle is that we’re not starting from scratch to build these from the ground up. We’re saying these are networks that already have a significant number of participants already, and they have to meet certain eligibility requirements as well as technical performance requirements to be considered a tougher network. And once they pass those tests, then they’re able to go live and connect it with each other.

Tom Temin And first responders. And that whole community often generates the initial information on health when they respond to someone who might be injured or burned or whatever the case might be. Are those party to TEFCA also?

Micky Tripathi That’s a great general example, actually, of some of the gaps that exist in the marketplace today, and that we want to be able to use TEFCA to help fill. So, as I said, there are a number of networks now. There are literally hundreds of networks across the country that exchange information. And the private sector’s actually done a fantastic job. Before joining the federal government in 2001, I was very much a part of that sitting on the boards of some of these nonprofit networks. And so I saw firsthand how much they had accomplished. But the private sector alone can’t do it alone, because health care, as you pointed out earlier, the federal government and state governments are very involved in health care. They deliver health care, they pay for health care. They set the rules of the road for health care. So it’s very hard for the private sector on its own to solve all these problems. And so that’s what TEFCA represents, is really saying, all right, the private sector has taken that as far as it can possibly do, it’s done a great job. But now we need public private collaboration with the power of federal government convening to help to bring that together, to say what are the other things we want to do?

Micky Tripathi One, is what I described, which is connecting the networks together. Second side of things is there are gaps that the market itself hasn’t really solved and has difficulty solving. One is, I should point out, first responders. So we’re actually working with a group of first responders who are now already working on joining one of the approved networks, so that we do have the ability then for first responders, ambulances and other first responders to be able to share information with provider organizations. Other gaps that I would point to, though, are public health, huge gap. Right now, even after a pandemic, public health agencies were not able to connect to the networks, the nationwide networks that exist today, for a variety of reasons related to the complexity of regulatory frameworks and the fragmentation of jurisdictions and all of that. Nothing the private sector can solve on its own. That’s something that the federal government, ONC and the CDC and jurisdictions working together. Last thing I’ll point to or two things. Another one is individual access. You as a patient ought to be able to access the network to get your own information. That seems like how to be fundamental. So we’re working very hard to say that’s what TEFCA needs to be able to support as well. There’s lots of complexity there. And that’s why, again this public private collaboration is needed. And then finally payers. Health care payers, they have been excluded from these networks for a variety of competitive reasons that exist in the market. Again, we as the federal government have been saying, you know what, we understand there are competitive issues, but that can’t be what prevents us to get to the higher level of health care interoperability that American citizens need. And so that’s we’re going to do is break through that to fill that gap as well.

Tom Temin And so in a lot of ways, the banking and credit card systems and clearances and there’s a whole complexity behind all of that. Or say the airlines have inter airline clearance mechanisms and payment mechanisms going back decades. Those are pretty good models too.

Micky Tripathi They are absolutely. There’s a lot of similarities there. I think one of the differences and why we need more of this proactive public, private sort of collaboration here, is that unlike those other industries. The federal government involved in all those industries, so it’s not as if it’s not. But the federal government plays a unique and very large role in health care that’s somewhat different than in other industries. And the other thing about health care is that it’s unbelievably fragmented, much more so than banking airlines that have a lot of consolidation to them. Health care is unbelievably fragmented. And so it takes something like the federal government to help to just convene everyone to say, all right, we’re going to get everyone together and work with states as well, to say we’re not stepping on states toes, but we need to have something that gives more system to our system. That’s the important role that the federal government plays on this.

Tom Temin And late last year, the TEFCA group,  updated from 1.0 to 1.1, which indicates the relative newness of the whole enterprise here in TEFCA.. But what changed recently.

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Micky Tripathi 2.0 is just about to happen. So, not to get too wonky here, so just set the table here for everyone just so everyone knows what’s happened. When we came into this administration, we said within a year we are going to get the TEFCA framework out to the public for the public to react to and provide us comments back in with an eye towards saying we’re going to go live. We’re going to have networks that step forward and say that they want to do this voluntarily, because the 21st Century Cures Act didn’t give the federal government, my office, any budget or any new authority for TEFCA, and explicitly said that TEFCA has to be voluntary. So I have no ability to order, nor does Secretary Becerra have the ability to order anyone to join TEFCA. So we have to make it a true public private collaboration model that say, how can we work together to get to something that all of us want and that the private sector sees as valuable? Otherwise they’re not going to invest their money. So within a year, we made available version 1.0 of this common agreement, which is a common contract that everyone across the country would sign if they want to participate in TEFCA exchange. So everyone knows the rules of the road. Again, if you’re in Nome, Alaska or Omaha, you know that if you have signed this agreement and you’re sharing information with the provider organization in Nome, Alaska, they’ve agreed to the same set of rules. You don’t have to worry about is there a different set of rules here that I don’t understand that are going to get me in trouble? So the next thing we did is we said, now we invite private sector networks to step forward and join TEFCA as networks. And I’m really pleased to report that seven of them step forward a year after, as a year ago, step forward and said we are committed to implementing TEFCA. Some of those are very well known, I think to a lot of people. Epic, for example. Very large  EHR vendor, they step forward and volunteer to be one of these networks, the Commonwealth Health Alliance, which covers Oracle Health, which is the VA’s system.

Tom Temin That’s the obvious one I was going to ask about.

Micky Tripathi Athenahealth, eClinicalWorks, Meditech are all under the Commonwealth Health Alliance umbrella. eHealth exchange, which has a number of federal government participants and at the VA, for example, participates in that as well as others. So significant network stepped forward, those seven and now a year later as of January, seven are now live. All seven of those are live exchanging information with each other. And then 2.0. What the 2.0 common agreement does, which we’re going to release before the end of the first quarter here, the end of March,  is it upgrades the technical standards to allow API based exchange for those who are technically knowledgeable, which is a more modern way of having information exchange in the same way that you download apps on your phone and make it that easy and that convenient. That’s what TEFCA will support in this calendar year.

 

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