ONC Chief Defends Health IT Investment Despite Cost of Ownership Concerns

In the second of a two-part interview, Micky Tripathi points to resources to optimize best practices, but says the ONC could do more.

Micky Tripathi, PhD, MPP, took the helm of the Department of Health and Human Services Office of the National Coordinator for Health Information Technology on the first day of the Biden administration in 2021. In a sequel to his two-part conversation with HealthLeaders a year ago, Tripathi addresses ONC's top priorities. Part 1, published yesterday, explored top ONC priorities including data governance, data sharing, security, and privacy. This interview that has been lightly edited for brevity and clarity.

HealthLeaders: Some healthcare IT leaders continue to express concern about the total cost of ownership of digital health technology going on back a decade. It's as if the government helped fund the purchase of cars, but did not budget for funding for the fuel for the cars. Enterprises say they don't have the resources necessary to necessarily drive home the potential of this technology. What can the government do to help?

Micky Tripathi: I'm not sure I agree with the analogy. Every industry has to move forward, and I think there's a tremendous amount of value that's been gotten already from these systems as well. With anything, and particularly with technology, the costs are very, very clear and discrete -- what you pay eClinicalWorks or Epic or Cerner every month -- but the benefits are very diffuse. So your CFO doesn't see on their ledger, here is the return on investment that I got from that, even though there is a return in terms of quality, in terms of safety, and better documentation. So I disagree with the premise that that analogy is right. I don't think that there's a choice in that matter.

There are a variety of federal programs that provide additional benefits. For example, participation in value-based purchasing, where there's upside potential for organizations that participate in those. You can't successfully participate in those if you don't have an electronic health record. And there's no way that you could do the kind of quality measurement, the kind of care coordination, the kind of care management that you're required to do to participate in those programs without the benefit of those systems. So that's where there's a lot of benefit. And I think we're going to start to see more and more.

Micky Tripathi, head of the Health and Human Services Department's Office of the National Coordinator for Health Information Technology. Photo Courtesy ONC.

We talked about algorithms. I have a little bit of a black box, and we need to worry about, are there unintended consequences for what's going on in there? There is a huge upside potential to what algorithms offer as well, when you think about the burden of too many clicks. Algorithms can work in the background, to try to make better sense of non-structured data to allow physicians to dictate in the ways that they used to be able to dictate into systems through natural language processing, so that they're not having to type all that information in. Those are all things that are tremendous benefits on the algorithm side, but also are part of the benefit side of the ledger, as we think about what electronic health records and health IT in general provides to people.

HL: Although to be fair, if you're adding elements like conversational natural language processing, that also adds to the cost side of the equation as well. It doesn't come with the EHR.

Tripathi: No, it doesn't. As data varies by the system, how much of that is an extra feature? Like any other investment decision, every organization has got to make the decision of, do I want to hire a scribe, who will do that kind of data entry for me? Or do I want to invest in that technology? Or do I want to place that responsibility on the provider? And these are all sort of the regular automation versus labor intensity kinds of decisions that every organization has to make.

HL: The ONC and the government are best known for writing and implementing regulations. How can the government move beyond this, to offer more in the way of workflows, best practices, recipes for success, educational curriculum, and sample policies. Some say adding these would improve clinical workflow in ways that similar measures do for aviation by going beyond regulations.

Tripathi: Yeah, it's really an interesting perspective. We would love more feedback on where we can do that more. We try to do some of that more, like we have the Health IT Playbook, for example. It's on our website, but that kind of walks through different types of capabilities and gets a little bit into workflow sorts of related things. We do a ton in the way of learning collaboratives and webinars and all of that, but if we're not doing enough, or if there are areas where we can do more, we are absolutely happy to talk to anyone who wants to help us with that.

We work with the AMA and others to develop joint educational materials and resources as well. The challenge with things like workflows is that once you get to a certain level of detail, it really varies by what's your specialty, and what EHR are you on. It's really hard to be generic, or to the extent that you are generic, people feel like that's just motherhood and apple pie, and doesn't apply to what they're trying to do.

One area that I think is an area that we're starting to look harder at, though, and since you mentioned aviation, is safety. Are there things where we can drill into more with respect to surfacing safety issues that might be common across EHRs, for example, and be able to surface those and make those available to others for them to learn and be able to make sure that they design certain things out of their systems? If that has popped up in one system, it seems like it could be an issue in other systems as well. And that's very much in line with the way that the aviation industry handles safety issues. Regardless of whether you're on Boeing or Airbus, or regardless of which avionics system you're using, being able to surface those issues so that others can learn from them, that's an area that we're starting to look at for sure.