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151: Tommy Ragsdale

Tommy Ragsdale, Director of Strategy and Business Development at the Center for Medical Interoperability, discusses the principles and concepts of resident data and information exchange. We dive into the questions of quality, security, and cost to utilize a seamless data sharing system in senior living.

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Center for Medical Interoperability

Lucas: Welcome to Bridge the Gap Podcast, the senior living podcast with Josh and Lucas here in person in Nashville. Got a great guest on today, Tommy Ragsdale, from the center for medical interoperability. Oh, I know this. Got it. Close, close. Our listeners know that these introductions are not easy and that’s not an easy one. So Tommy, welcome to the show.

Tommy: Thank you so much. It’s great to be here.

Lucas: Yeah. So we got introduced to Tommy via one of our mutual friends, Charles Turner, who, you know, immediately when I reached out to Charles, I’m like, “Hey, we’re going to be in Nashville. We’re looking for really good people to interview.” And you know, he said, “you need to reach out to Tommy.” You never know with Charles. Right, right. You never know, like, is he setting you up for a prank? Is he setting you up for something like some big thing, but Charles pulled through on this one. So Tommy, we’re excited to have you on the program. We had a pre-call a couple of weeks ago. Very, very interested in what you’re doing. And so for our listeners, I think let’s just rehash kind of, we almost wish that we had recorded that initial call because it was such a good fact finding and discovery conversation that I think it’d be helpful to walk our listeners through, so tell us about what you’re into.

Tommy: Yeah. And by the way, I’m flattered that Charles would even connect us and that you would think that this is going to be a good discussion as a result. But that’s great. Yeah. The center for medical interoperability is a really interesting place in that it’s, what’s called a cooperative R & D lab for the industry. Now this discussion is somewhat new for me. And the reason I say that is because the focus of our lab has always been on the inpatient side of the house and it’s been on the technology and the way technology does and doesn’t work together in that setting. So talking about senior living, you have a lot of the same challenges from what I can deduce, definitely on the information system side of the house. Maybe, maybe not on the device side of house per se, and we can dig into that more. But it’s, certainly a new conversation for me to see where do these principles, concepts that we’ve been maturing over the last several years apply here and where don’t they?

Josh:  So principles and concepts. Let’s dive into that because I remember just a little bit of our conversation that I can in no way regurgitate. So we’re going to have to rely on you to just kind of tell us a little bit about what you’ve been working on in the other side of the house, kind of in that inpatient stay and maybe what are some of the implications. And I think even in our discussion, we were kind of thinking, I think there’s a lot more implications here than what, you know, we even thought in the initial conversation and there could be, so tell us more.

Tommy: I kind of think about it on two levels. The first is where the center for medical interoperability was initially founded. And that is the collaboration exchange of data and cooperation between and amongst the modalities that are at the bedside. Whether we’re talking about an ICU in OR or an ED. So examples, infusion pumps, patient monitors, ventilators, etcetera, working together with each other and the applications that might be in that room. Like an electronic health record or a clinical decision-making application, the way the world works today, each of those modalities are siloed. They don’t work together. They don’t collaborate to ensure that that produces a positive outcome. They all just work on their own. And the clinician that’s there bears a hundred percent of the burden of making them work together. So we have a, a human, a fallible human in that critical, critical juncture. So that’s, that’s kind of the first level, right? That trusted exchange of data and cooperation at the bedside. The next is, what, what about when we go from organization to organization. As a patient, as a business relationship between and amongst organizations, we need that same sort of concept of trusted data exchange there, particularly with such a valuable, and crucial data set as healthcare data. And I say that in a big blanket term. So, that was what the center was founded for to establish that framework and the supporting elements to that. And we can dive into each of those.

Josh: So before we get to talking any more about the implications and things like that, I’m just really, really curious as to the why. Why is it that we have all of this technology that at some point is all siloed? I mean, is it because technology has evolved so fast that no one was really kind of masterminding, How is this all going to communicate? I mean, you’re probably going to have to dumb this down for me, but that’s just a curiosity that’s here with me now.

Tommy: Yeah. I think there’s a couple of reasons. One of those reasons are that a number of the companies that live and work in this space have been around for awhile and have developed solutions before there were such things as organizations coming together to set standards. They had to come up with their own solutions and thus they were proprietary. Then that kind of calcifies itself by, evolving over the next, however long five, 10 years after that, to becoming a market advantage. Because if, if my stuff works with my stuff, then you as a client, a customer are incented to just buy my stuff. And I don’t really have much of a market reason to make it work with everyone else. So that that’s part of it. The other thing is I think that we have an understanding of technology working together by what we see in our personal computers, internet type of world.

There were a couple companies that were so far out ahead of everyone else in that development from through the seventies, eighties, nineties, etcetera, ie Microsoft, Apple, that they set the ground rules. And there were only two players that kind of had to figure it out. So there wasn’t near the complexity that we see in healthcare, as we talked about on our call the other day, at least in the inpatient side of things, there’s roughly 6,000 hospitals across the United States. And the largest health system only has about 180 of them. So there’s just so much fragmentation both at the provider level and that cascades down into the technology solution level. That’s so hard to bring all that together.

Josh: Well, it makes a lot of sense. So, you know, we were trying to compare and contrast a little bit to the world that you guys have been working on in that inpatient world and compare that to, you know, the senior housing, senior living. There’s a lot of different names for it. There’s a lot of variation in product, but one thing is pretty certain that we’ve seen through at least the last 15 years that I’ve been in the industry is, you know, this acuity creek, right? And it used to be a very residential social model. Now it’s become kind of hospitality meets healthcare. The regulatory environment is sporadic at best. It’s a state regulated businesses as our listeners know, and with that comes a lot of different standards. But the acuity everywhere is kind of the same. It’s creeping in with that. Our, our operators, our caregivers, our providers, whatever we want to classify them as, they’re faced with this challenge, probably much like the inpatient world has been challenged with. We as providers are not really licensed to do much more than we’ve always been licensed to do, but we’re being required to coordinate a lot more because of the acuity.

So what that looks like practically speaking is, as you guys know, is we have all kinds of emerging technology coming in, everything from, you know, monitoring different things, vitals for residents, monitoring movement in the room, monitoring everything. And so all these technologies, and then we’ve got electronic health records. There’s not a standard one. There’s a variety of different ones. Dozens of them actually all being used. And so the care coordination piece is very fragmented at best. And we’re relying in our industry, also, I think one of the challenges is a, a labor force that is built around really activities of daily living, not true healthcare. But yet we’re monitoring and coordinating a lot of healthcare things. So with that, you know, I, I turned it to you. Our last conversation I’m like, “it seems like there could be some implications here that would, the things that you guys are working on could be very, very relevant in real time, senior living today.” So what would you respond to that with?

Tommy: I certainly agree in the sense that what our job as facilitators of technology and enablers of technology is to do, is to reduce the burden on that caregiver. I mean, what you just described is the ever expounding burden that they’re now bearing. They weren’t trained to do it. A number of them are not what we call digital natives. Didn’t come up in a digitally enabled world, and that just creates a lot of challenges. So, why do people look to big tech today to make a positive impact on healthcare? Because they’ve done so good with user interface. I mean, my three-year-old doesn’t have any problem with an iPad because it’s so simple and that’s kind of the hope here. It’s not as easy as just saying, “Hey, big tech go at it,” because there’s a lot of that’s fraught with a lot of implications from number one, as we’ve mentioned the standardization is so fragmented, the data sets are not clean and then comes in the whole privacy and data security and those sort of issues that are things we’ve looked at. We’ve tried to put forward frameworks for, but they’re not technology problems, they’re business problems. Meaning, is someone going to give up their proprietary hold on something so that we can break through to that next level of productivity. That’s really how we look at it as a frontier of productivity, we’ve pushed up against, and we need to break through. And I, I would dare to say it’s very similar in that part of the industry, the senior living side.

Josh: So behind the curtain, give us some actionable steps here, you know, in your mind, you’ve got this organization that is actively working on this for the inpatient world. Is there anyone like you, others, like you that have identified senior living as a frontier that we’ve got to tackle these issues? Or is it one of those things where, “Hey, you’ll tackle it for inpatient world and then we’ll just carry that same platform over,” how does this really work? I mean, how do we get going in the right direction for our industry?

Tommy: Yeah, that’s a good question. I don’t think that there’s any organization that I’m aware of doing similar work. Sure, we’d like to say, “yeah, we’ll establish a platform approach to this, with the right kind of supporting elements and everyone can take it over.” What’s different here and what’s made inpatient kind of standalone here is, is some of, like you said, government regulation. Back in 2009, we had sweeping regulation come out of the office of national coordinator that incentivized electronic healthcare or electronic record adoption, but that’s all it did. It gave a bunch of money and said, go buy these things. It didn’t say, well, they need to connect this way. It needs to have security level this way, etcetera, etcetera. It just kind of said, here’s some money and that kind of made the problem worse. And from my understanding of those dollars, there are a lot of parts of the industry that didn’t get touched with those dollars. Therefore they didn’t adopt electronic health records and may have a chance to kind of build it right the first time. And I think that’s the opportunity that probably exists in senior living.

Josh: Wow. So, you know, how interested is your organization in something like this? I mean, taking this on, how do you guys get funded to work on this? How can the senior living industry, if our listeners are out there saying, “he’s preaching. How do we get on board with this?”

Tommy: It’s a great question! So lets talk a little bit about what our tactical evolution looked like. You know, we originally started out as an organization that defines technical specifications, meaning you got a technology solution, it needs to meet these rules, these requirements, and then follow that up with testing and certification. You bring your technology solution here, we run it through the appropriate certification process, and then you kind of get stamped with that kind of good housekeeping seal of approval. And that informs the buyers, right? Whether it’s the hospital or the senior living community, whatever, I know what I’m going to get out of that product, at least as far as, you know, interoperability and security and that sort of stuff goes. We morphed a little bit when we said that this need exists outside of the acute space. Meaning organization to organization and such. And, there are a lot of what the industry might call products out there, but we looked at it and said, we need an agnostic non-proprietary platform that can enable this.

And we built a demonstration of that in our lab, and really we’re fortunate, about 18 months ago, when we contracted with the center for disease control to deploy it along a specific use case. And you may remember from our call before that specific use case, ironically had to do with personal protective equipment and the resiliency of the industry under a pandemic and all that work started before COVID happened. So it was very timely. It gave us a great opportunity to talk about our concepts of a platform and a framework that enables trust city data exchange, but to do it with a use case. Because if you just talk about the technical ambiguity of a platform, it kind of goes in one ear and out the other. But if I talk about how that’s going to help you, maintain control of your data, but also be able to report certain requirements like personal protective equipment inventories, in a safe and trusted way that that resonates.

Or if we talk about care coordination for the population that your industry care of, that’s really important as they go from one setting, you know, in the senior living, setting back into the acute, back into the sniff, you know, whatever it is. That movement is, is really important. So we were able to deploy that and now, that platform exists and the effort is to articulate more valuable use cases. We’re kind of in a chicken and an egg situation where I kind of need to come up with some of those to get people understanding what is valuable out of the features of this platform. But I also need the industry to look at it and say, “Oh, this can help us with this problem that we have.” So it’s a little bit of that. I’m confident though, that once we get the flywheel going, the ideas kind of start to come and people look at it and say, “Oh, that’s going to help me with data exchange. I have a data exchange problem here.”

Josh: Yeah. Well, I think that’s right. So hopefully even this conversation today, a lot of people, because I know I’ve been in this industry a long time, talked to a lot of people, Lucas, and I talked a lot of people. My mouth was dropping a little bit in our first conversation. I’m like, why have I never heard of you? Why are we not talking about this? Because I think we’ve all just kind of gotten to this point where we’re like comfortable with a broken system, right? And we’re not challenging ourselves to why can’t this be better? What do we need to do? So, you know, I think there is this healthy friction, maybe it’s unhealthy, that exists between the regulatory environment, and, let’s just say private pay senior living for sure. And there’s this big push for quality standards in our industry. Many of our conferences, many of our organizations, member organizations, nationally have done some great efforts around trying to come up with quality standards that voluntarily providers adhere to.

And you get this label put on your right. And I think one of the real big pushes for that is because I think there’s this kind of unspoken rule and kind of conversation behind doors that’s like, look, if we don’t do this ourselves, then government’s going to do it for us. And it probably won’t be as pretty. And it probably won’t work as well. Where do you see this fitting in? I mean, you know, back to your chicken, egg illustration, do you think this is something realistically that the government’s going to have to come in and say, here’s dollars incentive dollars that your industry has to figure this out, or you have to adhere to this? Or do you think this is something our industry can set a quality standard that other industries can look to?

Tommy: That is almost certainly where at least on the acute inpatient side of the house, things are heading. And we know that because of regulatory efforts out of the ONC in the last 12 to 15 months that are aimed at breaking the data open. Because when you look at least on the acute inpatient side of the house, there’s very much this instance of data being locked down and held close to the vest. And in part of that is a lot of it is self protection, because no hospital or health system wants to be responsible for data breaches or for misuse of data, because HIPAA is, is wielded very much in that direction. Where we see a real opportunity, regardless of the episode or setting of care is this new wave of regulation out of the ONC is requiring technology providers and care providers to allow their patients to access data. Also to allow services, to access it on the patient’s behalf. That’s a real kind of a sticky situation if the framework isn’t correctly established. So to your point, the government’s taking it to a certain level and sort of hoping that the industry comes in and takes it the rest of the way. And, that’s where we see it’s either going to happen in the way that it should, utilizing an industry platform that’s agnostic. Maybe the industry owns it holistically, or it’s going to continue to be broken, but now data’s going to be kind of seeping out at a pretty constant rate.

Josh: So 2021, coming off of an exciting, interesting 2020, what’s on the horizon? what do you think is kind of the next, the next thing, if we, if we’re having a discussion with you in another six, eight, 12 months from now. What is, what is going to be the thing we’re talking about related to this?

Tommy: So for sure, in April is a clause out of that regulation that creates significant fines for providers, healthcare providers, and technology providers for data blocking. That’s going to be a big one that people are going to have to deal with. It’s going to be a big one, that’s going to have to be figured out in the courts like there’s no precedent there. It needs to kind of be massaged, but that’s the first kind of domino to fall. As far as all this goes, it was originally intended to be enacted this November. Obviously COVID has kind of pushed a lot of these timelines further and the ONC pushed it April, to provide a little bit more time for people to be compliant. So I think that’s going to be the big one. And that just kind of leads up to APIs, application programming interfaces for data access. Now that’s another couple of years down the road, but there are wickets that people are going to have to meet in the meantime to be ready for it. And from what I’ve seen outside. And in some cases in the acute space, people just aren’t ready. They’re waiting for their vendors to make them compliant. And our approach has always been, that’s a very risky place to live.

Josh: Well, it is a risky place to live, but I’m sitting here and I’m gonna play devil’s advocate. Cause I’m sitting here as, as an operator in my day job. And I know there’s operators listening. We’ve got a broad audience that’s tracking with you like understanding. And then there’s a bunch of operators sitting there and it’s like, I don’t know what the hell he just said. Like, what is the, what is the practical steps to be in compliance? If you’re going to put it on the shoulders of that owner/operator, that’s not going to look to their vendor to say, please keep me compliant. What do they do? Is this a, is there a chief technology officer that they need to, is there an organization they need to reach out to? Because the majority of the operators in our business are small. They’re regional operators don’t have big IT departments much less compliance division. So what would your advice be to them?

Tommy: It’s certainly tough, depending on the size of your organization. There are a lot of resources on out there on the web, just to kind of figure, get a little bit of familiarity with it. Now, as far as becoming compliant, some of those organizations are going to have to rely on their vendors. But what I will say is, don’t just take what the vendor gives you or tells you as gospel. Walk with them through that journey, because, what we’ve seen on the inpatient acute side is just the providers kind of just listening to the vendors and letting the vendors kind of dictate the terms. And in some cases that makes sense. In some cases it works. But the way we see this data piece playing out is the providers are the ones who are probably going to be ended up holding the bag at the end, if there are issues, data breaches, etcetera. And, we think that an appropriately architected framework and platform like we’ve begun to deploy the foundations of, can really go far for a provider or a technology provider to look back and say, we took virtually every step we could. We, we did solid digital identity of who we are. We, we encrypted our transactions. We logged them all. We did our best due diligence. Sometimes things are going to go awry, but, you can look at this and how we’ve participated and the rules we’ve followed and did the best that we could.

Josh: So you’re a huge, valuable resource. This conversation doesn’t need to stop with this podcast. Our listeners, ourselves need to continue to educate ourselves more on this topic. I’m going to imagine many of our listeners have never heard or talked or even thought about talking about this topic until today. I hope I’m wrong. I hope I’m on an Island, but, um, if they’re not, do you guys at, at your center, at your organization, do you guys have some resources that we can connect our listeners to?

Tommy: We certainly do. You know, you can get a little bit of that stuff on our, on our website, but you can also connect directly to me and we can get, you know, email addresses available. I’m happy to engage in any of those conversations. In some scenarios, we may be able to help in some, we might not, but at the very least, I think everyone would be more informed on the back.

Josh: Good. That’s great. Yeah. Well, thanks to our buddy Charles Turner for connecting us with you. Thank you for taking awesome time. We will connect our audience to you. What a great episode.

Lucas: Yeah, no doubt. We’ll connect to Tommy in the show notes, and we’ll also connect on BTGvoice.com. You can go there and get all our resources, including transcripts of every podcast that we do. In case you didn’t know that we got to know a lot of new listeners this year. So go to BTGvoice for all the resources, connections to all of our social media and all of our content. Thanks for listening to another great episode, Bridge the Gap.

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151: Tommy Ragsdale