We all know that interoperability must be solved, but what’s the first step we need to take? Doug Fridsma believes it’s in changing the definition. “We need to stop thinking of it as a ‘utopian place’ where data can freely flow.” Rather, it should be viewed in a much simpler and more practical way — as “incremental added functionality.” In this interview, the CEO and president of AMIA talks about why interoperability wasn’t baked into Meaningful Use, why he thinks FHIR has great potential, and why patient access has become such a big priority for his organization.
Fridsma also reflects on his time with ONC, discussing some of the difficult decisions that had to be made and why he believes a “front-loaded incentive program” made sense when it came to Meaningful Use, and talks about the work AMIA is doing to advance the field of informatics.
- 5 years with ONC
- Taking “the path of least regret”
- ONC’s approach to standards: “Hedge your bets”
- HITECH as the infrastructure for EHRs
- “You can’t develop interoperability in a committee.”
- More city planning, less architecture
- AMIA: “We’re representing patients.”
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One of my mottos at ONC was, ‘we want to take a path of least regret,’ because we had to adopt certain things. There were regulatory mandates and timelines we had to follow, but at the same time we knew that there could be better solutions, and we didn’t want to box ourselves in.
The way you manage your retirement portfolio is you hedge your bets; you make sure you’ve got a balanced portfolio of different things. What we tried to do is to create a portfolio of standards that we knew we could rebalance in the future if we needed to.
We knew that you couldn’t develop interoperability in a committee. You had to do in the real world. We also knew it was going to be messy after we adopted all these records, because it would be challenging to get them to talk with one another.
There’s an implicit evolution that has to happen with the technology that we use, and the smart CIOs and others will build into their technology and processes ways that will allow these things to change.
I think sometimes we mischaracterize the problem. The problem isn’t one of architecture. The problem is one of city planning. It’s different than designing a building. It’s about creating the incentives and the structures that allow robust cities to grow and thrive.
Gamble: You’ve been with AMIA for about three years, correct?
Fridsma: Yes. This November will be my three-year anniversary. I’ve been with AMIA since the fall of 2014, and I was with ONC from 2009 through 2014, so about five years.
Gamble: I can imagine there were a lot of learnings from that experience that have helped shaped the role you have now.
Fridsma: When I was at ONC, I was the director of the Office of Standards and Interoperability, and then later the chief science officer for ONC. My job was understanding and conveying some of the hard technical details so that as we tried to turn Meaningful Use into policies and regulations, we’d have a good understanding of what the pros and cons of different technology solutions applied to those different policy options might be. There was a lot we learned.
Early on, we had to adopt standards that existed because we simply didn’t have time to create ones that would be better than what we had. One of my mottos when I was there was, ‘we want to take a path of least regret,’ because we had to adopt certain things. There were regulatory mandates and timelines we had to follow, but at the same time we knew that there could be better solutions, and we didn’t want to box ourselves in or adopt a solution that we knew couldn’t adapt, and change and grow.
At the time, with some of the early work of Meaningful Use, for example, around vocabularies for drugs, most people were using proprietary ways of recording the information for drugs. We knew the National Library of Medicine was working on a drug vocabulary called RxNorm. And so rather than having everybody make radical changes to their systems and adopt RxNorm in the first round, Meaningful Use Stage 1 said, here’s a list of 17 vocabularies or drugs that can be mapped to RxNorm. And so in the first cycle, we’re going to constrain what you’re going to do by picking a vocabulary that can map to RxNorm, knowing full well that you can anticipate that in the second round of regulations, we’re going to ask you to adopt RxNorm.
So that gave the industry some time to consolidate without necessarily pulling the rug out from under them. Similarly, we adopted two standards of Meaningful Use Stage 1 with CCD and the CCR — two different standards for clinical care. One was a clinical care record, one was a clinical care document. So the two were related, but not identical standards. And then in Meaningful Use Stage 2, we consolidated those two and created what’s called a consolidated CDA, which incorporated the CCR and CCD viewpoints into one standard continuity of care record and the summary of care.
We tried to anticipate that. We did not adopt a full suite of V3 messages from HL7 — that was the current state of the art, because other countries had done that. England and Canada had adopted the full suite of V3 messages, and they turned out to be very challenging to implement, as well as expensive and a little bit unwieldy. And so we adopted one just because we needed to get one thing out there, and then allowed flexibility for things like FHIR to come down the road.
I think our approach to standards was more like managing a financial portfolio than it was to pick a particular stock and go all in. If 30 years ago, you knew that Microsoft was going to go gangbusters or that Apple was going to go crazy, you could’ve gone all in, but you never know that. The way you manage your retirement portfolio is you hedge your bets; you make sure you’ve got a balanced portfolio of different things. What we tried to do is to create a portfolio of standards that we knew we could rebalance in the future if we needed to. As one standard became old, we could replace it with a new one, but we wanted to make sure that the portfolio all worked together, so that we’d have vocabulary standards, transport standards, and structured document standards, and know that we could swap out a transport standards without disrupting our content standards. Or we could swap out or update the vocabulary standards and not necessarily disrupt our content standards.
We saw this really as a portfolio where, rather than having a million proprietary ways of doing things, you only had, for example, 17 with drugs, and eventually one. I think that’s the approach that we took for a lot of the standards work that we did. That’s probably not information that people know.
Gamble: No, definitely not.
Fridsma: Because we don’t really talk about it, but now I don’t work for the government anymore, so I can talk about it.
Gamble: Right. That’s a really interesting look at how things were. I imagine it was really valuable having that look into how things are pushed through and how things work from that with HHS.
Fridsma: I think one of the things people don’t realize is that Meaningful Use was not an infrastructure building exercise. It was part of the stimulus bill, and it was aligned with some of the administrative priorities, because if you want to get to value-based purchasing, you can’t do it by abstracting paper records. You have to have an electronic way of collecting data that you then could use to determine the quality of services that were provided. It doesn’t scale if you have to go into every doctor’s office and do chart abstraction to figure out whether or not they qualify for the payment incentives and things for providing higher quality of care. You had to get into an electronic way of dealing with medical information if you wanted to get the payment reform.
It was no accident that two years before the Affordable Care Act was passed, HITECH came out and started to develop the infrastructure for electronic health records. But it was primarily geared toward adoption of electronic health records — not interoperability, and it was tied to an incentive program that was front-loaded. I remember being on calls with the administration — it was the vice president’s office that was primarily charged with the stimulus bill — and saying, ‘If you can’t get the money allocated and out to the people, to the doctors and hospitals and others that are out there, then we’re going to take the money away and we’ll use it to build a bridge. Because we’ve got to unstick the economy and we’ve got to try to get money out there to help stimulate the economy.’
There was a lot of pressure to try to move very quickly, and so I think we knew that we could achieve the goals of adoption, because that was the principle charge of the HITECH Act. We knew that you couldn’t develop interoperability in a committee. You had to do in the real world. We also knew it was going to be messy after we adopted all these records, because it would be challenging to get them to talk with one another. But we knew that to try to do it in a committee and in a hypothetical was probably not going to be successful. And so by getting it out there and making it messy, but providing mechanisms with a portfolio of standards that we could adjust and adapt as technology changed, we thought that was a better strategy for getting to a more sustainable interoperability than to try to define what interoperability should be in a committee and then deploy it. I think that would have stifled innovation. I think it would have stifled new approaches, and FHIR probably would have never happened, which I think has been a good thing for the industry in terms of the adoption of standards.
Gamble: Yeah, that’s a really interesting perspective because I’m sure this doesn’t surprise you, but we’ve heard people ask time and time again, why wasn’t interoperability baked in? You can see when you really break it down and look at it that there was no way to do that and have it be effective. You needed to get in there first.
Fridsma: Yes. And to get the money out there under the auspices of HITECH. There was an understanding that the systems weren’t going to be perfect, but by thinking about the set of standards as a portfolio, kind of like what you would do with your financial retirement, it also gave you the flexibility to modify and change and adapt. I think one of the things that CIOs and others think is, ‘I’m going to adopt this electronic health record and then I’m done. I don’t have to do anything more. My job is done now.’
The reality is you’ve adopted an electronic health record and you have just started your journey, because as health care changes and as care delivery changes, your technology has to change to change with it. Once you have it in an electronic format, you’ve got to be able to figure out ways to continually modify and change. Again, while the same thing that applies to standards applies to information technology, a technology that you never use is a technology that you never change, right?
Fridsma: One of the things that perhaps wasn’t explicit is that there’s an implicit evolution that has to happen with the technology that we use, and the smart CIOs and others will build into their technology and processes ways that will allow these things to change. I used to have CIOs come to me when I was at ONC and say, ‘We just spent X millions of dollars, and we’ve got our system installed, and we’re all excited.’ And I’d say, ‘That is fantastic. Now, as you’re thinking about this, have you thought about the next system you’re going to install?’ It’s probably not the right thing to ask after you’ve gone through the pain and hardship of putting in the first system, but it’s an important question to ask, because you’ve got to build your systems for obsolescence. You’ve got to build your systems for evolution. Computer technology and things like that have paradigms you follow that would allow you to change one aspect of your system without disrupting other parts of it. And I think we’re still learning how to do this at scale.
I think sometimes we mischaracterize the problem. The problem isn’t one of architecture. The problem is one of city planning. It’s different than designing a building. It’s about creating the incentives and the structures that allow robust cities to grow and thrive. And so, what do you need? You need zoning laws. You need police and fire protection. You need basic infrastructure — water, sewer, electricity. You need building codes to make it safe. You need zoning laws that help you incentivize certain kinds of structures in certain kinds of areas.
There’s a whole host of things, and if you think about the problem of interoperability in EHRs as one of city planning and not one of architecture, it starts to define everybody’s role. What’s the role of government? What’s the role of industry? And what’s the role of doctors, patients, and others, because everybody has to serve a particular role. And if you think about it as building to building, it tends to be too technology-heavy, and we know that the kinds of problems that we’re trying to solve are really socio-technical. They’re not just technology; they’re about workflow integration, education, professional development, and teaching people how to be good users of the systems. All of those things are important, and so framing as the problem as one city planning and not of architecture really broadens the kinds of solutions that you might come to.
Gamble: Right. It just makes sense to look at it from that perspective. So you’ve pretty much answered what I wanted to ask about what made you interested in coming to AMIA; it seems like it was the logical next step in seeing things through.
Fridsma: I get to participate in many of the same conversations. I just get to sit on the other side of the table now.
Gamble: Right. Similar content, but a different viewpoint for you.
Gamble: And it seems like it was definitely seems like it was the right move for you, and you’ve found a good home there.
Fridsma: I’ve been a member of AMIA for over 20 years. It’s been my professional home ever since I was a medical student. My first meeting was in 1996, which is hard to believe, but yes, it’s been a long time. This is my tribe. These are my colleagues and friends. These are people who think about problems in the same way that I do. We’re not selling products. We’re not out there representing vendors. We’re representing the informatics community. We’re representing patients.
A lot of times, I go up to the Hill and we’ll visit with Congressional representatives and members of the Senate, and we’ll tell them about AMIA. We’ll tell them about some of the things that we’re concerned with, and some of the issues that we think are right. But at the end of the day, our ask is never, ‘We need this particular legislation passed or we need this particular restriction lifted.’ Our ask is, ‘When you start to tackle these hard problems of interoperability, and usability, and data blocking, all these other things that people are talking about — when you start to handle those problems, just call us. Let us contribute to the conversation, because we have 5400 members that are just waiting to be able to apply their skill and expertise in informatics to some of these really hard problems.’
And so, we don’t sell a product. We’re a 501(c)(3). We’re not a 501(c)(6). We’re not a trade association. We really are a professional organization that’s there to advocate for the safe and effective use of information technology and the use of informatics to leverage and make the most of that technology that’s out there.
Gamble: All right, I think that that wraps up what I wanted to talk about. Really great stuff and I think that this is going to be enlightening for our CIO readers and other health IT leaders just to give them a window into AMIA. It’s been great hearing your perspective, so thank you so much for your time.
Fridsma: You’re welcome. We’re happy to help in whatever way we can.
Gamble: Sure thing, and I definitely hope to speak with you again. I’m sure that there’s always going to be enough to talk about.
Fridsma: That’s the great thing about informatics these days. Years ago, I always had to explain it to people and now, everybody wants to be one. So it’s not a bad place to be.
Gamble: No, definitely not.
Fridsma: Thanks so much. We’ll talk to you soon.
Gamble: All right, thank you. Have a good day.