In part two of the Healthcare IT News Q&A with Micky Tripathi, he lays out the ways interoperability can finally be brought to fruition in the U.S. over the coming decade. Hint: the federal government and the private sector each have big jobs to do.

[See also: Interoperability: supply and demand]

In our chat Wednesday with Tripathi, CEO of the Massachusetts eHealth Collaborative and co-chair of the joint HIT Policy and Standards Committee's JASON Task Force, he offered some perspective on how and why interoperability has historically been such a problem for healthcare – and discussed lessons that might be drawn from other industries that were able to make it happen.

With the Office of the National Coordinator for Health IT now redoubling its efforts to make seamless, wide-reaching data exchange a reality within the next 10 years, he gives some further thoughts on how it all might play out.

[See also: Taking out interoperability hurdles]

Q: What role can the government play in guiding this journey? Obviously, the initial goals of HITECH and meaningful use have been a success: EHRs are now commonplace. But that was accomplished with the help of $27 billion. Now that that money has mostly been paid out, how much can the feds really do to spur interoperability? Is it up to ONC to just use its bully pulpit to encourage the private sector to act?

A: That's a fantastic question. ONC is now in the process of creating this interoperability roadmap that you may have seen – they put out a vision statement and have a three-, six- and 10-year vision, and they are now in the process of fleshing that out, and they're going to be releasing that on a schedule where they're going to be asking the federal advisory committees, the policy committee and standards committees, (for input) in mid-October and they're going to be releasing their next iteration of that and asking for comments. And then I think the idea is that by January they'll offer a more fully-blown out roadmap.

They've had different input from different groups and different experts, and one of the things that came up at one of those recent roundtables was the very question you're asking: What role does ONC see itself playing in this? Because if you look in the three- and the six- and the 10-year visions, it's like, OK, that's great, as a vision: By year 10 we want to have a learning healthcare system.' Well, let's get an operational definition of that.

But then the question is, who's doing that? Does that mean ONC is going to go back to Congress and ask for $100 billion for that? I don't think that's what they're saying. And I think they're starting to give greater thought to all of the various levers they have.

So bully pulpit, as you mentioned, is one of them, and I think there's something to that. But there's also sort of a wide range of levers, and each of them on their own couldn't do anything, but if ONC could play a role in orchestrating those, it could have, I would argue, at least as powerful an effect – if not an even more powerful effect than meaningful use.

For example, payment models. As we know, most of the accountable care activity going on in the country these days is pioneer ACOs and Medicare Shared Savings program. Starting to build more and more into those programs – reimbursement based on activities that you can only do with interoperability is the kind of thing that creates more of an incentive for people to just go out and demand interoperability. And that's pretty powerful.

Even in the fee-for-service area – you may have seen just the other week that CMS said they will start now, even for people who are on fee-for-service models, that they will start paying PCPs for care management activities. Whereas before, the joke among physicians was that, 'CMS will pay me to clip someone's toes, but if I spend half an hour thinking about a care plan for a complex diabetic patient who also has congestive heart failure and other comorbidities, I get paid zero.' Well, now CMS is agreeing that there's something perverse about that and will actually pay for care management activities.

So that, then, creates an incentive for people, now that they're being paid for things like that, to invest in systems that will get me the information so they can do care management activities more effectively.

There's those kinds of levers, there's levers related to the different regulatory authority they have. CLIA – the lab certification program that CMS has – they might be able to start implicating the lab certification process, saying, 'Oh, by the way, lab, not only are we going to come in and certify you based on good manufacturing practices within your lab, we're also going to talk about, are you doing lab codification according to LOINC, which is a national standard.

Or talk about the DoD and the VA. Maybe that's a lost cause (laughs), but on the other hand they are very powerful and they spend a lot of money on care delivery. If you can start to align some of those things, that could be very powerful in the market.

Nursing homes. Every nursing home and home healthcare agency in the U.S. has to submit OASIS forms (Outcome and Assessment Information Set) to Medicaid. Those are completely non-standardized and not aligned with what meaningful use and the standards we have for interoperability require, in the way of C-CDAs and XML. If CMS just started to say, all that stuff has to be reported using the interoperability infrastructure and tools we've given you through meaningful use, again, you could start to see nursing homes investing in EHRs that can do that now in order to be a provider on the Medicare network.

We just recently saw a presentation from ONC where they're starting to inventory all those levers, and starting to say, 'Now how do we put those into buckets and think about how we can orchestrate those in a coherent way.' To me, that's incredibly powerful.