Marcia: Thanks for talking to us today. We know you don’t have much time, but we really want your feedback about vendors being able to connect with, solicit opinions from and participate jointly with the government in helping the digital health community and its impact.
But first, I wanted to say that your book, “Innovative State” laid out such a strong narrative for participating in public/private innovation and it’s a relatively new concept spurred on by the current administration. Do you think enough entrepreneurs are participating in it?
Aneesh: Thank you for the question and the opportunity.
I would say three things.
One, it has historically been in the DNA of our U.S. government that we’ve had many periods when the government was just ahead of the private sector on the use of new technologies, or new capabilities for solving problems. So, it’s been part of our history, even the past 20-30 years looked like it has lagged far behind.
Number two, when you look at the muscles that we’ve trained, when it comes to engaging with government, they’ve largely been focused on two — asking the government for money or asking the government to regulate for or against a particular industry or capability. These have been muscles of government intervention where people have been lining up on either side. Maybe to those cynics, it’s a bit of a corrupted process to those who believe it is working.
It’s a great deal of consumer protection and investor certainty and high quality economic performance, but the missing part of our muscles have been around collaboration and in today’s digital era, the best opportunity of all is the government being a collaborator on digital assets, especially in the regulated sectors like healthcare. If you think about most of the analogies that you hear today with the era of Big Data, the opportunity with the Internet of Things — information is in many ways the new oil for the information economy and Saudi Arabia would thus be either the government or regulated sectors where information is controlled or managed or regulated by government.
The opportunity to make a difference, at least in the digital space of the health, energy and education markets absolutely must include a conversation with the public sector if it’s going to be successful.
Marcia: And what do you think, Aneesh, holds back those entrepreneurs who are not engaged in the government conversation?
Aneesh: First and foremost, the people who go after the problem first will find inevitably that they engage with government. In other words, there isn’t a problem for the entrepreneurs who start with the proposition: “I want to help an accountable care organization or a physician who is just trying to practice medicine to take better advantage of these new technologies to care for the population that they are responsible for.”
If the problem that the entrepreneur is trying to solve is helping that provider transition to value-based care, they don’t need anyone from the government to remind them that there’s an opportunity to collaborate. They're there. They are working with the Medicare ACO claims data. They are pulling information out of the Centers for Disease Control and the NIH. They are engaging because they are focused explicitly on problems.
The Health Datapalooza is a program that my successor Todd Park jump started at the dawn of this open government era. We’ve now seen thousands of developers gathering annually to demonstrate how they’ve solved real-world problems, in part, by accessing and using open data. McKinsey has estimated that 200+ companies have already been born where their products have had some dimension, and then improved by accessing open government data.
So I’m not so much concerned about whether or not entrepreneurs are getting the message. I’m mostly interested in the friction between those who see a problem, but may not be as capable of accessing the resources that are actually available, and they don’t know about them to solve it. That friction is really right now and where the energy is focused on, in reducing barriers to that friction, encouraging folks to test and prototype products off of the open data sets; that was a big hallmark of my successors work to go out to developer communities, reducing that friction and explaining to them how the problems that they want to solve can benefit by accessing and using this data set.
Marcia: I’m really curious, Aneesh. Who do you give credit to for opening government data for the private sector to use? Did that come from you?
Aneesh: Oh no. Historically, a figure by the name of Thomas Jefferson gets the credit, because Jefferson really put open data at the heart of his strategy around the weather. Jefferson himself was rather a bit of a weather enthusiast, and so he had made the judgment that when Lewis & Clark traveled west, they would collect weather data and make that available to the American people upon their return. Jefferson himself was publishing open data freely with his fellow weather enthusiasts. With the spirit of Jefferson, and the weather ecosystem that has emerged in the digital era, every weather service in the five billion dollar annual industry builds on top of the weather data made available by the National Oceanic & Atmospheric Administration. So I would start the credit with Jefferson.
In the modern era, I would say President Reagan with the work that he had done in opening up the GPS system, with President Bill Clinton’s help in allowing it to be commercially available. So Reagan builds GPS, and Clinton basically opens up the rules that GPS can be used for commercial purposes. That combo became the next chapter, in many ways, of open data. And frankly I do believe this to be a bi-partisan effort, meaning Republicans are just as enthusiastic about open data as Democrats. For what purpose or what problems to solve may be difference of opinion, but what President Obama had done was to say that I want this to be the default setting of government. I think scaling up a culture of openness begins and ends with President Obama’s leadership, as exhibited by his day one action to create a new open, by default, strategy.
Millions of people are engaging around the world in open data. There’s an international open government partnership that includes leadership from all over the world. President Obama is one of many leaders encouraging this, and the rest of us are just execution arms. We are doing our best to bring the vision to life from these incredibly thoughtful leaders.
Marcia: As I read your book, your example of the 1904 Boston Fire that left the city burning, it really illustrates what can happen when an industry or government doesn’t address compatibility or standardization issues and of course we have that issue today in healthcare. Companies like ours at Catalyze are bridging that gap between new technologies and providers, but what more do you think can be done in that regard?
Aneesh: In my view, interoperability has three dimensions:
1) Demand for it. Because of the shift in payment, today, three, five, eight percent of a provider’s income is tied to value-based or alternative payment models, where they are actually incentivized to go build up a larger portfolio of information about the patients they are responsible for. As that moves up as a share of their income, the demand from the delivery system for interoperability will grow. Today, it’s not absolutely necessary to be interoperable, if you are entirely fee-for-service, because it’s useful to reduce errors, but it’s not mission critical. The demand signal for this, I think, is tied very closely to the pace of payment reform, which has only been accelerating in the public sector, now that Secretary Burwell has said that she wants 50 percent of all Medicare payments through alternative payment models by 2018. So that's number one.
2) Cultural. Today, when you and I walk into the Gap and buy something, the clerk hands us a copy of our receipt. There’s a sign on the wall that says, “Tell us if the clerk didn’t give you a copy of your receipt.” The default in retail is: information is shared. Unfortunately, we’ve seen a culture where by and large that’s not the default. You discharge out of a hospital and you’re supposed to get a discharge plan. It’s supposed to be made available to you in electronic form. Yet, two-thirds of hospitals in America publicly reported in Stage 1 Meaningful Use that not a single patient requested an electronic copy of that care plan. Is that because the patients don’t want it? Or is that because the culture is not yet attuned to the notion, like at the Gap, where you get that copy on your way out the door by default? In my humble argument, that’s more of a cultural issue than anything else.
3) Last but not least is a technical matter. We have been grappling with the technical standards in interoperability for many years and we’ve largely been building our interoperability strategy around documents. Can I assemble a digital version of a manila folder and ship that across the delivery system? Largely that’s a use case of a patient being in front of me, so I quickly grab all the information about their history so I don’t make any mistakes and I can close any care gaps. That’s an interesting problem and we’ve made a great deal of progress in moving those documents around, both on the privacy, security and technical side. But for the apps ecosystem that we all envision emerging, and what I hope Catalyze and others will bring to life , we need access to discrete data. We want to reduce the friction of having to convert information to documents and then parse those documents back into information. We loose a lot in that translation step. So, HL7/FHIR gives us the opportunity to leapfrog this document exchange era and move into the discrete data exchange era. More importantly, regulation has already started to define it. Just because I can transmit discrete data doesn’t mean that we mean the same thing when it’s transmitted. So at a minimum, a meds list in a Meaningful Use Stage 2 certified EHR will be the same as a meds list from another vendor in Stage 2 certified EHR, because they both agree to transform that data at the edge to comply with the RxNorm standards, so that when they share, it’s in a common language. This notion of moving to discrete data and on standardized content — this is the step that we are taking and I think the final hurdle on the technology front is regulating that there is one person who has the right to that data, end of story, and that’s the patient. So Meaningful Use Stage 3 just went final and basically said that the patient deserves the choice of whatever API endpoint that they choose — the app of their choice that can consume that FHIR API on that standardized common data set. And that’s where we are today and why I’m so excited that for the first time we can have plug-and-play apps as part of this ecosystem.
Marcia: I think the key takeaway from your book is the promise that information is becoming more connected between private sector and the government and by doing so it will make it much more efficient for all those who depend upon the government for a better America. As you look back on the legacy that you left as the first U.S. Chief of Technology, and then with your successor Todd Park and later Megan Smith, what are you most proud of?
Aneesh: For me, I’m most proud that Todd took the job after me, because I love that man like a brother, and I think he has taken the capacities of this country to the next level. So that’s my narrow proudest accomplishment was recruiting Todd.
But more broadly, I’m most proud that we brought to life what the President stood for in opening the government up by default. We really had to tackle the cultural and policy challenges as we moved toward the era of open connected APIs, cloud first, mobile first, etc. These technologies are certainly coming online faster and better, and they are being deployed in ways that we expected them to, whether it be in the recovery of healthcare.gov, or in some of the lean startup activities that we prototyped in the first term.
I’m most proud that we’ve set a new culture and created new muscle in the problem-solving gym, which says that if you want to tackle an issue in the 21st century, yes, you might want to look to regulate; yes, you might want the government to fund or operationalize something, but you might equally look to the government to play that convening role. To think about more data sets that may be available, either that are not public today but could be, or those that are available but not in machine readable form, or for the government to play a role as a Switzerland or convener on standards that lower barriers to interoperability and foster more collaboration, or even running government programs themselves more like a lean startup, which is now the new default.
Last but certainly not least, tapping into the expertise of the American people through challenges and prizes so we don’t rely on the same beltway bandits to solve every problem that the government puts out on the technology domain. We allow people in all walks of life and every corner of the country to participate by visiting challenge.gov. I think these muscles — we started them in the first term, under the President’s leadership and we’ve seen them scale up with Todd and Megan. I don’t really want to put too much emphasis on us, meaning this CTO role; we are just a mechanism by which this capability is being brought to life. It’s the tens of thousands of government employees, every single day that are using these new policy muscles to solve problems. That’s what is exciting me —since this movement has been born, it’s not turning back, no matter who is elected in the next cycle, no matter where you go around the world; this is a new muscle that will be part of our problem solving tool kit and I’m proud to have played a modest role in bringing it to life.
Marcia: For those entrepreneurs that don’t speak the language of government, how would you encourage them to participate and make their voices heard and technologies seen?
Aneesh: First and foremost, visit healthdata.gov and explore all the opportunities to incorporate new resources to make your products better. This is not a charitable endeavor; this is product development. If you are blind to the data assets that can be used to make your product better, you are missing the boat in serving the needs of your customers, especially in healthcare. Put your product development muscle on and think of this as an input, as any other input.
For number two, I do believe that this mystical idea that Washington works by lobbyist and insiders can be demystified by the notion that engineers who are capable of contributing a little bit of their time — three, six, nine months a year — either to work in the government as Presidential Innovation Fellows, or collaborating with the government in specific areas like Arien Malec and RelayHealth, who took a leave of absence to develop effectively safe, secure email standards by direct protocol. He came in as a Switzerland voice to solve a very specific problem with not a lot of lobbying, power and other kind of political experience. That’s the idea: Product developers should not miss out on the opportunity and individuals who feel like they have a voice to say how our country should be run can now participate through all these vehicles. We’re just getting started, so I would say, pay attention to the opportunity.
Marcia: Thank you so much. We know you have a hard stop. We thank you so much for participating in this Innovation Series and we love your responses. Everybody go get the book “Innovative State.”
Aneesh: Alright! Thank you very much for that. Have a great day.