Much is unsure on the health policy front as we await a new administration and new Congress in 2025. But in the world of health data sharing, enough momentum has been built up in terms of standards and infrastructure that it is difficult to imagine the train slowing down or changing direction too much. A veteran of the last decade of progress on interoperability, Rhapsody chief product officer Jitin Asnaani recently spoke with Healthcare Innovation about what we might see next year.
Asnaani’s career has given him a great perspective on how interoperability has progressed over the past decade. He served as executive director of the CommonWell Health Alliance and helped to launch and lead the Argonaut Project, which drove the development of FHIR APIs, and the Direct Project, which created secure push-based messaging for healthcare. Asnaani also has led corporate development at digital health-focused companies Bamboo Health and Health Gorilla. Now he leads product development at digital health enablement company Rhapsody.
Healthcare Innovation: Where do you think we’re likely to see the most progress on interoperability next year? For instance, will we see more use cases involving FHIR APIs mature? Are there other areas we should be watching?
Asnaani: I think we could say a few things about FHIR pretty conclusively. One is we’re going to see more of it over time, and that’s a good thing. FHIR was developed to solve some of the problems and limitations of existing standards as well as to solve new problems that existing standards could not solve. I think we’re going to see broader and broader use of its abilities to exchange discrete pieces of data in modern formats. But our reality is that while FHIR is built in many places, its adoption is more sporadic than advertised, and that will continue to be the story over time,. Ten years ago, when FHIR was invented, there was so much hype about how it’s going to change the world overnight, and for years, nobody at all was using it. Now some folks are using it. It’s wonderful, but it’s still being used on a really paltry scale relative to how much it should be used and will be used.
HCI: What are your thoughts on TEFCA in 2025? I just saw a presentation by ASTP’s Micky Tripathi, and he listed off some of their accomplishments so far, in terms of getting governance in place and building trust, which is a huge challenge. Would you say that they’ve accomplished quite a bit already in a fairly short period of time? What should we be watching for on the TEFCA front in 2025?
Asnaani: On the TEFCA front, Micky Tripathi’s team has been incredibly disciplined and pushing hard to move the TEFCA ball forward. There’s no doubt they’ve made a tremendous amount of progress. CommonWell, Carequality and then eHealth Exchange all were huge proponents of query-based interoperability. Micky Tripathi’s administration came in and he pushed TEFCA to enable and expand what those organizations were doing by formally creating this mechanism for these organizations and others like them called Qualified Health Information Networks. ONC did this for several reasons. CommonWell, Carequality and eHealth Exchange were starting to hit an asymptote in adoption that was not close to 100%.
CommonWell, Carequality and eHealth Exchange were all community-driven activities, so the communities that believed in them did that. That leaves still a lot of people on the outside who are not sure. They might say, ‘I’m taking care of my patients just fine. Maybe I don’t need to do it.’ You have all this doubt and uncertainty when you have three separate community-driven organizations. Even if they are working together, it still leaves room for doubt. So the government coming in saying that this is going to become the law of the land over time, and will be part of incentives and disincentives over time, now providers need to pick one.
I think what they’ve done was incredibly important for pushing the industry forward. Now I finally answer your question: In the coming year, what is going to happen? I was there at the recent ASTP annual meeting and that was the big question which nobody could answer. One thing I know for sure, we’re not going back. So TEFCA has pushed the ball forward quite a bit. Query-based exchange is becoming part of the national fabric. If the next administration carries it forward, then it will become even more broad-based. If they don’t, the community initiatives that started it, as well as the now-existing QHINS that the federal government has put into existence, will continue carrying the ball. What the tapestry will be and will we have more players? I don’t know. I’m not going to speculate on market balances there, but we’re not going back to the days before query-based exchange.
The crystal ball is murkiest when it comes to use cases. Since we don’t know what the new priorities will be, what’s going to be the state of HHS as a whole, given the whole shift in administration, and what their policy priorities seem to be, that’s the part that’s hardest to tell. I do feel excited, though, honestly, David, that regardless of where they go with the other use cases, there’s going to be a tremendous amount of of energy around query-based exchange.
HCI: In his recent talk, Tripathi mentioned one goal that I think is ambitious — patient notification of how their data is shared. For instance, a patient has an application on the network, and every time their data is exchanged by the providers, the patient gets a notification. That’s very different from how things happen now.
Asnaani: There are two parts of it that are ambitious. I fundamentally believe that’s a great idea. If my data were being exchanged, I’d want to know that my data is being exchanged. What Micky pointed out is that this is technically feasible. I actually don’t think that’s the hard part. I think the harder part is, will people actually use it and is there going to be a policy priority that drives it? Will we overcome any objections from the community and make that happen? Frankly, I don’t think there’s going be a ton of objection, except for the objection of doing additional work for patients who may or may not use it. So I think we have that to get over, but I do think technically, it’s that hard to do, particularly if you’re using some sort of patient identity matching that allows you to be able to correlate that with an actual patient to whom you can then send the data. There is actually a little bit more under the hood that needs to be done, but I don’t think that’s the big challenge there.
HCI: We’ve written quite a bit about what’s happening in California with their data sharing framework, and part of that is trying to pull community-based organizations into the data sharing ecosystem and incentivizing them to get on board. Is that something that you will have your eye on over the next year?
Asnaani: It’s going to be incredibly interesting to see how that develops. To be frank, that part of the community has been underserved in terms of interoperability. They have a very broad array of different types of data they may share, and a broad array of needs. They were not subject to any of the HITECH Act funding that happened 15 years ago, which drove the adoption of EHRs, so it’s a much more fragmented space. It will take more work, I think, from a policy perspective, and it’s going to be very slow going. I do think individual communities have the opportunity to make big inroads there. I know we’ve made big inroads in the State of Maine, where I’m involved in the HIE. I know California is trying to make big inroads there, but I think we are still some years away from this becoming a national phenomenon.
HCI: You mentioned being on the board of directors of the HealthInfoNet HIE in Maine. Let’s talk a little about health information exchanges in general. Several of them are rebranding as health data utilities to emphasize the broader role they can play in supporting many use cases for a state, including public health. But are there challenges for the HIEs as well as opportunities in the year ahead, and does TEFCA have anything to do with that?
Asnaani: From a pure interoperability marketplace perspective, I don’t think there’s anything new, per se. I think the health data utility aspect started with looking at the HIEs that were incredibly successful, and noting that they had certain characteristics and drivers that positioned them for success. Other HIEs are in a position of trying to discover a way to drive that sustainability by providing a value to the community that allows them to get on a sustainable path. The health data utility concept did a really nice job of framing something that seems to be the pattern for success and that can inform future policy making, more than anything else.
The HIEs were already under pressure from CommonWell, Carequality, and eHealth Exchange. That train had already left the station. To the extent TEFCA accelerates the train, then yes, maybe some HIEs won’t have time to make the pivot. But if they’re expecting to be funded for the same type of exchange that the QHINs are already doing, those HIEs are in trouble regardless. They have an uphill battle. They have to make a pivot.
HCI: What about data exchange between health systems and public health agencies? That has always been a struggle, perhaps in large part due to the underfunding of public health.
Asnaani: I think the public health domain has a little bit of a stutter step that happens, right? You see them make a little bit of progress. It comes from a bolus of funding typically, and then for a while— at least from the outside —it seems like it plateaus. For example, in the HITECH Act, there was a bolus of funding to enable connection to immunization registries and so on. That was a big step forward. It was done in a very federated manner, so that was probably more work than it needed to be across the community, but at least it moved the ball forward. During the COVID crisis, there was more funding that allowed new efficiencies and more to be reported to the CDC.
HCI: The pandemic also made it painfully obvious where there were gaps in how data needed to be shared…
Asnaani: That’s 100% right. It put a spotlight on where the deficiencies are, which meant that that there was more political pressure to address those deficiencies. I don’t see anything on the near-term horizon that’s going to get us that level of focus again and near-term political pressure again. In fact, I’m more worried that it’s going to be a little bit of the reverse. You tend not to step backwards. Usually, the worst case is you don’t step forward. I’m excited to see whether they are able to continue using the pressure from before to more efficiently manage the funding they have now.
HCI: Another thing that was mentioned at the recent ASTP meeting was a whole-of-government approach requiring federal agencies such as the VA and CMS, etc., to use USCDI and FHIR APIs. The federal government makes up a pretty big chunk of what’s going on in healthcare. Do you see these interoperability requirements being put in place as a significant step?
Asnaani: I think that’s going to be incredibly important. I started my career in healthcare at the ONC for two years, primarily under Farzad Mostashari at the beginning of his time as national coordinator. And I would say getting that coordination within the federal government itself is a huge service to the country.
HCI: What are some other things we should be watching in terms of interoperability issues in 2025?
Asnaani: We haven’t yet talked about AI, but we’re going to be able to do more and more with it because of the this movement of data. And a lovely part about this from a political perspective is that, for the most part, interoperability is bipartisan. Priorities might change from party to party. One national coordinator might have a slightly different set of priorities, strengths, and so on than another national coordinator. But for the most part, movement along all dimensions is actually relatively bipartisan.
Things like TEFCA or FHIR APIs are tackling a set of narrow use cases, and the goal is to build more use cases over time, but it takes a long time. But there are tools to tackle a broad variety of use cases right now. Rhapsody alone has 1,700 customers across the globe who utilize our products to be able to connect to a variety of different data sources for a variety of use cases. There’s more opportunity for interoperability that’s not necessarily spelled out in a federal law.
And as you get more types of data in different formats, that volume of data itself is not necessarily a predictor of success. It’s the ability for that data to actually be useful to you so that you can do the things that you want to do — build that AI algorithm or improve the patient or provider experience. If you’re getting lots of data that you don’t know how to utilize, you’re really not able to do anything powerful. So the ability to, for example, map identity, so that when you get data from different places, you know the data about an individual actually corresponds to. Then you can actually participate in whole-person care or patient-centered care.
HCI: So it’s about the curation of that data…
Asnaani: Exactly. It’s turning that data from raw, disparate data into information that actually can provide you an insight. I’m very excited about the industry in general being able to turn this data into information that’s useful. And then, of course, we have these analytics companies, AI companies and so on who can then take that information and turn it into a brilliant insight that can be utilized, maybe even automatically utilized, to improve care downstream.
