Healthcare in the 21st Century


Bill Russell / Aneesh Chopra

Aneesh Chopra 21st Century Cures

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August 7, 2020: Aneesh Chopra, First CTO for the US elaborates on 21st Century Cures. How should CIO’s prepare? How do we scale an interoperability strategy that is built on the patient’s right of access? Our industry finally has a chance to self organize and standardize data elements for sharing. Why have the banking, education and energy industries beaten us to the punch? How do we approach intellectual property issues? We also look at payment reform and value based care.

Key Points:

  • Data sharing policies for COVID lab reporting [00:12:36] 
  • Interoperability in support of the patient equals better health outcomes, better health and a better community. [00:13:21]
  • One doctor who’s had an electronic record for 30 years can’t even give a list of patients who smoke because it was not a structured field in the EHR! [00:19:19] 
  • Why has healthcare, 10 years after the initial data set was published, not added a single data element beyond the minimum required in the open source domain? [00:21:33]
  • How dangerous is a compliance mindset? [00:27:47]
  •  21st Century Cures [00:28:05] 
  • Information blocking [00:32:16]
  • Intellectual property issues [00:33:33]
  • Apple Health [00:41:17]

Healthcare in the 21st Century

Episode 287: Transcript – August 7, 2020

This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.

Bill Russell: [00:00:00] [00:00:00] Today. We’re joined by Aneesh Chopra. Good morning. Aneesh,  welcome back to the show. 

[00:00:04] Aneesh Chopra: [00:00:04] Thank you, Bill. Pleasure to see you again. 

[00:00:06] Bill Russell: [00:00:06] I’m looking forward to this conversation, but let me give the listeners a little background on you. You’re the first CTO of the federal government author of the innovative state, how technologies can change government co founder and president of care journey, healthcare analytics company [00:00:21]but you also wear a couple more hats, right? Carin Alliance,  Biden cancer initiative among others. bottom line, you like to stay busy. 

[00:00:30] Aneesh Chopra: [00:00:30] We have a lot of work to do to make healthcare better. Bill. We got to do it. 

[00:00:33] Bill Russell: [00:00:33] Yeah, absolutely. Where have you been spending the majority of your time over say, the last couple of months?

[00:00:39]Aneesh Chopra: [00:00:39] I would say, COVID related data sharing problems emerged as a major priority. It wasn’t tied to any sort of, you know, business proposition or anything that had a formal responsibility, but. many organizations, many people, and I presume you must’ve felt the same way. I want to do something. I want to be [00:01:00] helpful.

[00:01:00] And so we kind of dove in feet first on where we thought we can make a difference. And so I certainly did a bit that I could, it’s probably stabilized about 30% of my time bill, but running care journey is a full time job. So it’s the 30% on top of the full time job. which is of course a challenge with a work life balance. [00:01:19] That’s a whole different subject for different podcasts. 

[00:01:21]Bill Russell: [00:01:21] , I’m excited. We have a little new format for this fall. We’re going to do a little longer conversations, so it’s not going to be more of the Q and a session.

[00:01:29] It’s gonna be more. I don’t know, just a back and forth natural conversation. So here’s how this is going to flow. Well, you, you and I used to do this when I was CIO, you’d fly to town or we’d see each other, we’d grab a table at a restaurant and you’d talk about what was coming down the pike in terms of, of regs and movement, specifically around Interoperability usually around interoperability, and then you and I would come up with a plan for how our health system could really leverage that to really move the needle forward, not just comply, but really.

[00:01:59] Do [00:02:00] something, do something exciting. I mean, these, these things provide a CIO, a platform to have conversations and to move things forward. And I used to love those conversations. So people are for this show, they’re going to get a chance to sit in on one of those conversations and see, see what we used to do, way back in the day.

[00:02:18] But before we, before we get there and that, and that’s what people are tuned in for, but before we get there, I wanna, I want to delve into one thing here. So  my youngest daughter goes to Baylor and, you know, she came home just like everybody else and has studied for a semester at home.

[00:02:37] And one of the things she, she came to me, she said, you know, Hey dad, if you’re up for it at night, I’d like to watch the West wing with you. And I’m a huge fan. I said, it’s such a phenomenal show. It was so well done. And, so, and it’s also a great opportunity to discuss the issues with your kids and talk about how the government works and all those things.

[00:02:56] And we’re having a great time watching the show, but, but you’ve got to live it, you, [00:03:00] you were there. So, I’m going to ask some questions on her behalf, the first being, you know, what’s the coolest thing about working in the West Wing. So 

[00:03:08] Aneesh Chopra: [00:03:08] every morning, I would walk into what’s called the Roosevelt room of the West wing, which is catty corner from the oval.

[00:03:17] You see it on the news a lot because you’ll see often the president sit in the table, conference room table, often surrounded by members of Congress or stakeholders, et cetera. It’s a place to get a lot of the media and statements out. But every morning I would walk into this room for the senior staff huddle.

[00:03:36] And I would pinch myself every single day because honestly, who the heck am I to be in this building? I was in awe of the importance that it conveyed. on a personal level, I found the seven to 10 minutes prior to the meeting, my most productive negotiation session. I’d grab a member of the cabinet or I’d grab a policy advisor to the president [00:04:00] to whisper in the ear, a thing that needed to get done.

[00:04:02] And then maybe the 15 to 20 minutes after the meeting where I might hear something and then go grab somebody to say, Hey, let’s build a plan. That was probably my most productive hour of the day pre during and post Roosevelt room, senior staff meeting. And that experience is sort of what you felt in the spirit of the West wing, which is there’s a lot of action, a lot of activity.

[00:04:27] We pack a lot of substance in a very short period of time. We went from international affairs to budget, to economics performance, to domestic policy, to science issues. All in a matter of, you know, 30 to 45 minutes with the pre and the post in between. So that was the experience for me was just, understanding the importance of the moment and to doing whatever we could to help the country get better.

[00:04:52] As you know, the recovery we were in economic crisis during the time I was there. And so. Every day had this doom and [00:05:00] gloom scenario and this sense that like, okay, we’re going to have to, we’re going to have to take a step forward together. And every single voice needed to be heard and action needed to be taken, to be, to be successful.

[00:05:12] Bill Russell: [00:05:12] You know, it’s interesting as you described that, I’m thinking about our staff meetings and the team was always like, wait, we have too many things to cover to fit this into 45 minutes. But for the federal government, I mean, you’re covering every, everything you’re covering the world, the budget, the, I mean, you’re covering everything.

[00:05:28] So the president of the West wing, oftentimes we’ll just look and go, okay, what’s next? Sort of like to say, yeah, I got it. Let’s let’s move on. I mean, was it sort of like somebody ran it pretty, pretty tight. Somebody was the scrum master. 

[00:05:41] Aneesh Chopra: [00:05:41] Yeah. So to be clear, president Obama himself would not be in these daily huddles.

[00:05:45] This is not the best use of the president’s time. This Rahm Emanual the chief of staff’s time. The basic construct here, Bill is that. the president’s closest advisors would, and that often involved his [00:06:00] communication strategy, legal counsel, chief of staff, you know, three or four, four core advisors.

[00:06:05] I was, I was a report. I reported to the president, but I was more than that extended 25 to 35 group. And so the, they were largely focused on sharing the president’s priorities for the day. And hearing are the things we’ve missed in the president’s priorities that our respective, unit corners of the universe, you could say, by the way, this is happening in our world, you should be aware of, or, here’s what we were planning on doing.

[00:06:31] Anyway. I hope I don’t like potentially a step on the president’s message. So we were mostly listening to the priorities. They already set reacting and then contributing back so that we had a, more of a coordinated. Approach and that often involved rulemaking. The announcements, some, some sort of a project that we’re getting kicked off or motivated that needed to be discussed in those settings.

[00:06:57] So it was not a brainstorming session about the future of the [00:07:00] world. It was a very specific set of actions that had to be taken and reactions to fulfill. 

[00:07:04] Bill Russell: [00:07:04] Last two questions. Just, I really have to ask, you know, the show sort of depicts first year, incredibly hard. You bring in these really smart people, but they’ve never run a government before. So it’s sort of like, you know, let’s get our feet underneath us and you have some missteps, you hire maybe some wrong people and, and whatnot, but you guys inherited a, a mess in terms of the economy.

[00:07:27]and so the first year is hard. The, the second year, you get pummeled because the midterm elections happen and you lose, you lose Congress. Then the third year you’re fighting with Congress. And then the fourth year, it’s an election year. I mean, that’s how they depicted on the West wing. Is that, does that pretty much feel like what happened?

[00:07:44]Aneesh Chopra: [00:07:44] well, I would say, this is important if you separate politics from policy. You’d have a different view about the experience. And so from a political lens, that first year of [00:08:00] stumbles are often things that are policy misstatements or communications flubs, or some something that captures the media attention.

[00:08:08] Let’s call that the New York times, Washington, meaning what you see and read about and the fighting and the back and forth, because I was the chief technology officer. 90% of the work that I did had less political sensationalism and more of the Washington where both political parties wanted to get it right.

[00:08:31] We had enough allies on the Republican side of the ledger who wanted to meet with us to talk about technology investments. That would be down payments on the future. And that was a very, very bipartisan domain. So. I appreciate and observe like from the outside yeah. Care reform fights and all the things that really occupied the time, but in my day to day job and the role that I contributed back.

[00:08:57] We saw much more of the collaborative [00:09:00] Washington trying to get to the right answer. So we didn’t have the same, I didn’t experience the same sort of frenetic behavior that you saw. in the West wing, I would say having left before the demise of Todd Park, my successor would have had a different experience, after that became front page news every single day. [00:09:23]but by and large, the bulk of the work we had done was sort of positive bipartisan.

[00:09:29] Bill Russell: [00:09:29] you know? And that’s, that’s a great transition right there. Cause you know, healthcare doesn’t really come up much in the show itself in the West wing show. And as you say, you know, until healthcare is sort of front and center, it’s not part of the vernacular.

[00:09:43] You know, when I would say to my parents, you know, secretary Azar or Seema Verma, they just look at me like. I don’t know who these people are. but the reality is that these are important. They were important roles before because they come up on the show all the time. I mean, they’re, they’re central to the things that we do.

[00:09:59]but how do you [00:10:00] think the pandemic has really changed those roles? 

[00:10:02] Aneesh Chopra: [00:10:02] Well, I will say on the positive side, the pandemic has revealed the opportunity to make progress through executive action. So let’s just a little bit of a, let me wind the tape a little bit. Bill uniquely American story about healthcare delivery is that the government is regulator on a private sector system.

[00:10:30] We are an operator in the VA and we are a fiscal agent in terms of, you know, balancing the budgets and thinking about American competitiveness. So you’ve got multiple hats on how a government thinks about healthcare and by and large actions that are needed, like healthcare reform must go through Congress.

[00:10:57] And we wait for that once in a generation [00:11:00] opportunity to get the affordable care act or the, you know, annual, absolute knock ’em sock. ’em fight on the physician. Pay back then, it was the, if you remember, we, we used the doc fix every year. you know, Congress would sort of, you know, statutorily say we’re going to cut doctor pay 20%.

[00:11:19] And then every year create a crisis that had them, you know, fixing it, whatever that means, and then tacking on policy along the way. So we had this like big capital P. You know, legislative branch, executive branch dance that required, you know, a lot of moving parts in the pandemic. We’ve realized we’ve got a lot of authorities on the books today that we’ve used some, but we have much more we can do to make the healthcare system work better.

[00:11:51] And no obvious area captures the imagination more than telehealth. So imagine the world . [00:12:00] It was a minuscule part of our reimbursement model. You had to be rural, you know, very narrow use cases. The private sector would fund stop, but it wasn’t really at scale. And now you’ve got the Lovango, Teladoc merger at 18 and a half billion, disclosure.

[00:12:17] I work with Lubanga they’re members of care journey, and I love Glen Tullman. the point here is that we’ve come a long way through effectively executive action on just one component of healthcare. Then you look at the payment authorities in terms of, how to allocate the funding for provider relief.

[00:12:36] They have a lot of policy levers that can introduce rules around, data sharing for COVID lab reporting. The big fight in Congress and in the public today about how poorly our data systems collect race and ethnicity information and other inequities. So the executive branch and the pandemic has sort of [00:12:56] exercised muscles that maybe have always been there [00:13:00] but have been cautiously used. And now they’re being used to their fullest because we have no other choice. There’s no turning back Bill on a lot of these items and we’ll get into that as you proceed this discussion. 

[00:13:08] Bill Russell: [00:13:08] Yeah. And the interesting thing is you and I could just talk about the news for the next 30 minutes and talk about, you know, the HHS database over the, know CDC database, but we could go down, we could go into the Lovango and Teladoc.

[00:13:21] We can talk to telehealth. but I, I want to focus in on something that you’re passionate about and I’m passionate about, and that’s really this, this whole idea of interoperability on behalf of, in support of the patient, better health outcomes, better health and our community. So, so you know, we actually, you and I have actually covered this on the show before, and you did a, a great episode on the redox podcast.

[00:13:45]with Niko. And if, if anyone has a chance to listen to that, that’s a great like background for this. We’re going to cover sort of the history of this real quick, but you, you went into a lot of detail, but let’s, let’s get into the history and it starts really with you CTO. So you, [00:14:00] you had a fundamental platform for as the CTO.

[00:14:03] Where you were not only looking at healthcare, but you were looking at banking, you were looking at energy, you were looking at it across all sectors, but you had a fundamental approach to it. Why don’t, why don’t you share that? And then we’ll, we’ll go into the conversation. 

[00:14:15] Aneesh Chopra: [00:14:15] Yeah. And so, and I’ll be clear, not me personally alone.

[00:14:19] Right? We have a team group of family, but, the group, you know, Todd, Peter Levitt, there’s a whole litany of people whom I love that reached the obvious conclusion. When you look at HIPAA in every scenario, we regulate business business to business transactions with the proxy statement about what’s in the best interest of the patient.

[00:14:42] And you’ve got to go through a lot of hoops to make sure you’re doing the right thing to that. Yeah. You may share information under these terms and you’ve got to make sure both sides agree to the terms. In, education, there’s a program called  similar to HIPAA, same concept. Your student records are sensitive information.

[00:14:59] We [00:15:00] want to make sure when that moves around the internet, it’s safe and secure banking regulations, same thing. Your financial information is very sensitive at the core of each of these legal frameworks is the idea that the individual has a right to access this information. In the context of the laws, it’s always in the form of a written document.

[00:15:21] I can petition the government to see a copy of the things you’ve, you’ve got on my, you know, about me, or I can petition a hospital or a petition, a school or a petition, a bank. And in all three domains, the framework is the same. I have a right. How do we think about that? Right in the digital era.

[00:15:40] And the answer was let’s build pipes. That allow for the information that’s held by these sort of legalized or regulated entities to be given to me. And if we build a technology strategy on a mandated, kind of, methods [00:16:00] data to me, we could conceivably scale, an interoperability strategy that is required to build on the patient’s, consent or right of access.

[00:16:09] And so that. Paradigm shift. We took it first to market through blue button. the VA and CMS were the ones to operationalize this concept. And now as we’ve moved to the internet API era, we now have a very clean, clear. Foundation for data sharing where I can pull in my claims history from my plan, my clinical records from the hospital, my primary care doctor, my specialist, I can aggregate all that information.

[00:16:42] And by choosing among a marketplace of apps, I may offer my doctor to be the app. That I trust to organize it and use it for my best interest. And we’ll see a whole new layer of competition in that applies to the banking industry. I can take my bank account from [00:17:00] chase, JP Morgan chase and give it to

[00:17:02] I can do this from my smart meter and my energy grid, or I can take my real time meter reading and give it to my solar panel. Distribution a app so that I can regulate, where I get my energy from at what time for maximizing the, the cost savings and, and education. So any one of these domains are all built on the same principle.

[00:17:24] Give me my data in a modern standards format that I can use. However, I wish as I navigate whatever the regulated industry is. Great. 

[00:17:34] Bill Russell: [00:17:34] So, so that’s it show’s over. We’re done. But the reality is at the time you were there, the banking industry had already digitized, education had for the most part already digitized energy sector had already digitized, but healthcare wasn’t at, even at that starting gate at that point.

[00:17:52] And so there was things that needed to happen because people would look at it and say, Hey, we have mint. And that works really well. And I can get [00:18:00] access to my meter data through different devices and those kinds of things now, but I still struggle to get my complete longitudinal patient record and give us a little bit, why, why is that and how are we going to, how are we going to take those next steps.

[00:18:16] Aneesh Chopra: [00:18:16] market failure. Market failure.

[00:18:19] This is not a technology issue. Although there is investment to be made. It’s a, a market failure in that. For whatever reason, I’m going to use the banking contrast to healthcare to make this in the extreme, when we did the affordable care act. And then the recovery act, we basically said the public policy of the country is to move towards value based care and to open up digitize the records and make them available for where they can be put to their highest and best use, but it deferred to the private sector.

[00:18:56] The implementation details. [00:19:00] Thinking about this for a minute, bill, January of 2010, was that the first time we publicly disclosed the minimum data set that we want every electronic health record to capture your labs, your meds, your problem list. You know, our mutual friend, John Glasser. He was an advisor to us at the time.

[00:19:19] And he said, I’ve had an electronic record for 30 years. I can’t give you a list of patients who smoke because it was not as structured field in the EHR. So January, 2010, we produced this minimum data set. What became known as the common clinical data set. It wasn’t even a regulation. It was like a proposal at ONC for the certification process.

[00:19:42] So the theory at the time was this would be the floor, not the ceiling. And that once we get the industry to organize themselves around standardizing good elements, well, of course healthcare is going to go finish the job. It’s like a propeller. Once you [00:20:00] spin it’ll self propagate and we can just capture the energy.

[00:20:03] Maybe we’d never have to regulate again. I’m being a little bit facetious, but in theory, the industry could do that in the energy sector. We put 10 billion into smart meters. At the same time, we put 35 billion into electronic health records. We did that convening in summer in the smart grid. So imagine if you had an electric car and you drive it to your grandma’s house and then, she’s got a meter and you want to plug it in for charging.

[00:20:30] You don’t want her electrical bill to bear the cost of charging your, a car. So we ended up data standard and operability standards so that they knew that they could charge back to your home in, wherever, you know, California. So. The energy sector, self propagated, a set of standards that they all worked on to this day.

[00:20:51] There has not been a single piece of regulation forcing the energy sector to develop common data standards. It’s [00:21:00] all been industry consensus in the banking industry in Dodd-Frank. We similarly said the consumer has the right in this case by API APIs to aggregate their data. There’s never been a regulation needed because the banking industry got its act together self-organized and built those standards by which the mint dot coms of the world could connect to the banks all within a regulated context.

[00:21:33] Why healthcare 10 years after the. initial data set was published. Why bill has the healthcare industry not added a single data element beyond the minimum required in the open source domain? Have we just been so busy? We can’t add a single element in 10 [00:22:00] years. It’s because 

[00:22:02] Bill Russell: [00:22:02] yeah, wait, you know, we don’t, we don’t tend to self.

[00:22:06] Organized the way you, you talk about, we tend to, I remember sitting across from another CIO and I said, Hey, and this was something simple, right? So we had a, you know, we had an health information exchange in Southern California. I sat across from him. I said, Hey, we’d like to share our data through this HIE.

[00:22:25] And the CIO said, that’s great. We don’t want to share our data with you. And I’m like, and I’m not going to reveal who that was, because, but to be honest with you at that point in history, That was well within their prerogative to say, yeah, it’s not in our best interest to give you our patient data. You guys can then go after our patients.

[00:22:43] We don’t want it. 

[00:22:45] Aneesh Chopra: [00:22:45] And that’s why you see the need. The, the, the, what you’ve just said is why Seema Verma said at HIMSS a year and a half ago when we were still meeting in person that effectively, and I’m [00:23:00] paraphrasing, you made me do this. You the industry in the failure to self-organize for any reason, because of the financial incentives, the market dynamics, whatever that compelled, what she said was a sort of anti-regulation anti-regulation but, you know, regulatory agency leader to want to impose some of the strictest and boldest regulations on interoperability.

[00:23:31]we’ve had in the industry in, in the decade. So that statement is almost like it’s not Nixon to China. That’s probably a bit extreme and it’s not, it may be closer to Jefferson saying I’m a small government conservative and then doubles the size of the government with the Monroe w with the Louisiana purchase.

[00:23:50] So, you know, it may be akin to that, but, but that is why, people have been complaining. So bitterly. These rules feel difficult to [00:24:00] execute in the next 12 months or 24 months, depending on if you’re a plan or provider, that’s got to hit all these milestones, but in the grand scheme of a decade long effort, we under delivered in many ways and we’re having to pay the Piper.

[00:24:15] Yeah. Now, because of that judgment that we couldn’t get. The industry has, self-organized my opinion, 

[00:24:22] Bill Russell: [00:24:22] Aneesh, there’s really two things here, right? So there’s, there’s a payment reform. There’s there’s value based care. This is where we’re going as a, as a country, as health systems. We’re trying to figure out how to get to value based care because, the, the, the cost of care from a national standpoint, from a GDP percentage of GDP, hi, from an individual standpoint, it’s bankrupting individuals and.

[00:24:45] And those kinds of things. So we know we need to drive down the cost and value based care is pretty much undisputed as the, the approach that’s, that’s where we’re going. But the underlying, the underlying technology to make that happen is this interoperability framework. [00:25:00] So it’s really both. And 

[00:25:01] Aneesh Chopra: [00:25:01] isn’t it.

[00:25:02] It is a friendly amendment. I would say the value based care as a way to deliver the cost objectives while retaining and boosting quality. That’s still in my view is a religious movement. Meaning everybody believes it is because on paper it is. We have waste in the system. We have fragmentation. If we coordinated, we could remove waste.

[00:25:26] The paper argument for value based care is unequivocal. The actual results. Are modest. We have to do more and you either are going to double down on the religion or you’re going to say we need something else. And so you do see political arguments to say that the heck with this, let’s put healthcare on a budget.

[00:25:46] You figure it out. We’re not going to go to value based care. We’ve thoughtfully micromanaged, a quality metric and a reimbursement formula and a risk adjustment. No we’re going to cap rates Medicare for all, or we’re going to cap [00:26:00] rates a Medicaid block rent. Take your political party, idea. And those are not value based care tools.

[00:26:07] Those are blunt instruments. And if we end up having to do that, because that’s the only other answer where the budget is out of whack, you can just cap it. I don’t think that’s going to make anyone’s healthcare better. It’s going to create all kinds of stuff. So yes, you need to care, but acknowledging this podcast.

[00:26:26] It’s not a guarantee that it’s the path to success 

[00:26:29] Bill Russell: [00:26:29] and you know what, and to be honest with you, this is partially my learning experience. Every time we get together, you, reign me in from some of the, some of the extraneous things that, cause I don’t live in that world as often as you do as most CIO’s, don’t live in that world as, as often as you do.

[00:26:44]but at the end of the day, I firmly believe. That interoperability, this is the place I think we all agree. Cause we saw you and a handful of other people from multiple administrations. Sit on that HIMSS stage and talk about the consistency of policy [00:27:00] around that. At least the technology and the interoperability over the course of almost two decades, if not more.

[00:27:06] And the reality is we need to engage consumers. And as a consumer, I can’t get to my data. you know, I can’t hire anyone other than the health system I’m currently seeing or the payer. Okay. Currently seeing, I don’t really have choice. I don’t have friends. There’s no transparency in the, in the transactions at all.

[00:27:25] And so we know from a, from a free market economy standpoint, that those things transparency and choice. I mean, these are the things that drive a market. Now, healthcare doesn’t operate really as a good market, but, but that’s the reason I choose to run really focus in as a CIO and say, look, I think it’s not only good.

[00:27:47]good policy. To have a good interoperability framework. So when I sit across from a CIO and they say, well, I can, I can take a compliance mindset. I said, well, you know, that’s all well and good, but you can do so much more for your [00:28:00] community if you embrace and champion this, because we could take this a lot further.

[00:28:05] So let’s go down that path a little bit. What you know, so now we’re, we’re sorta be forced to, again, 21st century cures. But it’s also an opportunity. It’s not just a force, but before we get there, run us through 21st century cures. No one does this as succinctly as you. 

[00:28:21] Aneesh Chopra: [00:28:21] So what is unbelievable about 21st century cures bipartisan 90 plus percent on both sides of the aisle, wildly, favorable, president Obama signed it in the, kind of lame duck session at the end of 2016.

[00:28:36] It said unequivocally healthcare information. Shall be made available through standardized API APIs and the fancy language that is the hallmark of this law is that the data sharing shall occur without special effort. Think about every HL seven interface you had [00:29:00] to launch for a specific project to connect to the HIE, to connect to a third party app, to connect to a whatever Pell health plan.

[00:29:10] You would not characterize that as, without special effort. So in order to get to without special effort, we need to have plug and play apps. And the cures act basically says the entire healthcare record without special effort to patients, to doctors, to pharma, to plans to whatever. Now this is the key that law.

[00:29:37] By the way, an important point, given some of the political debate over the regulations, the congressional leadership did not say pending somebody else’s privacy review, the consumer can or cannot actually exercise their rights. They said they have these rights, the right to the consumer, and then effectively by contract to all the other stakeholders.

[00:29:58] So [00:30:00] Congress made it very clear. That gave the office of national coordinator and the CMS administrator, all the foundation they needed to state the following. We are going to tackle technical and nontechnical. It’s funny in international trade bill, they call these non-tariff trade barriers that on paper, you’re not actually technically doing something wrong or right, but you’re doing something indirectly that’s causing harm.

[00:30:27] So the analogy would be in cloud computing. You’ve got to have data centers on soil. Well, if you’ve got a UAS based cloud company, they’re not going to be putting data centers in every country around the world, that would be a non tariff trade barrier. So information blocking became the term around the non tariff trade barriers that were inhibiting progress.

[00:30:49] But the good news is we now have a very clear recipe from the cures act, our pace. For achieving the vision of the [00:31:00] law of all data to all stakeholders without special effort is constrained to the pace of standards. Consensus. If six CEOs in a room said, this is how we’re going to communicate this person’s, homelessness at us, we can reach consensus.

[00:31:21] And scale it to every community in the country because the cures act gives us that power. So a lot of my time and effort bill has been to try to put my energy where we can achieve consensus with neighbors and friends that want to make progress. And even if the neighbors and friends make progress at a slightly faster pace than the rest of the industry.

[00:31:45] Because of the law, we have the ready to take that idea and to make it assessable. And there’s no single provision, more obviously central to this than how we got the bulk fire requirement as part of the ONC [00:32:00] rules. And we may get into that, as a technical matter, if you wish. 

[00:32:05] Bill Russell: [00:32:05] Yeah. So I mean the foundation for 21st century cures patients at the center, so I can request my information, and no special effort, which is what you said, but it’s, it’s interesting.

[00:32:16] Cause some of the pushback came from EHR providers. Some of the pushback came from health systems and so there needs to be protection. They’re almost at protection. Well maybe it is protections. That’s a great day. So to, to make sure that they, they don’t interfere. Right. So there’s penalties for information blocking, but there’s, there’s also this idea that, that, that they can’t, and that’s, that’s, that’s this whole idea.

[00:32:41] And you’ve talked about this as net neutrality. Can you cover that concept a little bit? 

[00:32:45] Aneesh Chopra: [00:32:45] Yeah, that’s a great point. So, so this is the, the net neutrality is a principle that state, that scales the patient. access to the B2B use cases. So bill, this is going to take a little bit of a, let me take a minute to explain the context.

[00:33:00] [00:33:00] If I have to let me take a step back. Every EHR, the system, other than Vista for the most part is built on a proprietary backend database. There’s a Cerner database, a Meditech database, Epic database. And they all are competing on how well they orchestrate physician facing services that link back to a database that can optimize the workflows and that, and that’s when you do demos, you sort of see all this happen.

[00:33:33] That means that if they were to expose that data, their data model to a third party vendor. They’re essentially releasing their intellectual property. Maybe it reveals their schema or how they do what they do. And that would allow for a competitor to essentially copy what they’ve done. And that’s against the spirit of the American economy.

[00:33:55] And I endorsed, we all built businesses that have value and we should defend our [00:34:00] value. We’re not a communist country where the government can just seize your private assets. But the patient right of access to no special effort for their entire health record puts the following burden on the vendors.

[00:34:14] They have to map their proprietary data to something that’s not proprietary. Now they have the right, even in this rule to capture the long tail of data elements into something that is obscure, bespoke, whatever. That is their interpretation of their, data model that can be open source or they can work together as an industry and say, let’s do this on a common language.

[00:34:39] And I think the industry is consolidated around fire and the regulators heard that loud and clear. So net neutrality is the spirit that the cost of delivering that conversion from proprietary data to fire, to an app that. Machinery [00:35:00] the cost of delivering that has to be free to the patient. But if you’re going to make that same feed available to health plans, pharma, whomever, you can only charge them this.

[00:35:14] You cannot put the thumb on the scale and say, well, Bill you’re funding a startup. They have no money. So I’ll, I’ll charge you in a little bit of dollars to get you to get access to my data, but Oh my goodness, Optum Europe, kajillion dollar Goliath, you could afford to pay me. Z net neutrality is there’s a fair market value for the service translation from proprietary to open to distribution, and everybody is equally treated from that process.

[00:35:45] And this is the most important point. While each vendor is subject to their own net neutrality. We’re going to witness some are going to charge a heck of a lot more than others. I can’t wait. Fees are disclosed this fall. I can’t wait to [00:36:00] see the fee structure between vendor a vendor, B vendor C. It’s going to be, it’s going to be fascinating.

[00:36:06] Negotiating skills. My point in net neutrality, it’s more than we get net neutrality plus. They have to treat everybody equally, but if you’re the hospital and you don’t want to impose those fees on your trading partners, cause you think they’re too high, I can decouple that step away from the vendor into an other party that I can run myself and maybe bring down those costs.

[00:36:36]if I believe there are, there are too high and that’s why you should pay attention bill in this net neutrality world to what the cloud vendors do. Google, Microsoft, Amazon Salesforce, Oracle, IBM, every year at the white house, I help corral them to make a , develop a FHIR based commitment at the blue button developer conference.

[00:36:57] They may be. The lower cost [00:37:00] option to go from proprietary to open to distribution. And that offering may be the most important, cost reducer that makes this interoperability to patients and to others actually work in a business model that is about moving, making value out of the data and its use as opposed to the value of selling the data.

[00:37:23] If you will, through the transaction. Alright. So 

[00:37:26] Bill Russell: [00:37:26] I want to hit on something before I’m going to go into full blown skeptics, CIO mode and start peppering you with questions. But before we get there, the two things, one is there are a bunch of companies out there. I mean, we had, we had funded two of them,  Hart and clearsense.

[00:37:42] There’s others out there. There’s innovacer. There’s I won’t even Nikos redox could do this. because they’re there, they’re already reaching into the EHR. They’re already providing a set of APIs. They, they could create those kinds of things so that those, those, those platforms [00:38:00] exist. But how do those platforms get access to the proprietary data or do they rely on the open data set?

[00:38:08] That, that that’s what they’re going to operate. 

[00:38:11] Aneesh Chopra: [00:38:11] So, this is where the regulations will meet lawsuits that rent regulations meet litigation. So. Say, let’s just take an example because maybe it’s the simplest use case. Let’s say I want to deliver clinical notes. I’m an open ear, an open notes guy, if I’m not mistaken.

[00:38:33]but, but let’s assume you want to make clinical notes available to patients. And, the regulation say that that data in class must be accessible. otherwise your information blocking if the patient wants their notes in November. If you don’t give them the notes, you’re an information blocker. So let’s assume for the sake of discussion, you not only want to make the notes available, you’ve signed on to open [00:39:00] notes.

[00:39:00] Let’s assume you want to deliver that to the patient’s mobile app, right along side, their labs and vitals and everything. Yeah. That’s in fire release for and most vendors are working towards a two year deadline. When that release has to be deployed. Under the, ONC rule. What if I want to deliver open notes this November on the existing 2015 edition of, of my API that did not include the notes.

[00:39:31] I want to add the notes to the list. I’m guessing your comments about heart clear sense redox. They may say to the hospital systems, I will take the notes. Package them and then convert them into the fire API. I’ll add that to the menu of what you should expose to consumers and the apps they trust. I can do that maybe in December, right?

[00:39:59] When the [00:40:00] rules kick in, how will the market respond? Vendors say no, no, no, no, no. Wait until we ship our four in two years. Or will they be obligated to allow that individual hospital to execute that strategy? And then what’s the reaction if that reveals intellectual property, that will be where the lawsuits come in.

[00:40:23] If there are lawsuits, I don’t hope that there will be. I think we’re going to have people reach common sense agreements that say there’s no intellectual property rights to notes. That’s the doctor writing. we should expose that without a lot of burden and, and we should be able to reach consensus on how to accomplish people that want to go fast.

[00:40:44]Bill Russell: [00:40:44] . So I’m wondering if this is like one of those Jeffrey Moore curves where it’s, you know, early adopters, laggards, those kinds of things.

[00:40:50] Is that what we’re seeing? 

[00:40:52] Aneesh Chopra: [00:40:52] Yes. So now that the rules are on the books, now you’re going to see the market decide. Do [00:41:00] I want to be the first in my community to go live? And, and maybe even champion that as a value add, or do I want to be the last to meet the compliance deadline and maybe lobby and pray for some kind of reprieve on the backend that maybe COVID I can’t do it hardship, whatever.

[00:41:17] And remember the politics when Apple health launched bill and they named the dozen systems that were the first to go live. How envious were all your other friends not named by the 12th and how much flack did they get from their bosses? Why are we not the most innovative? How come we’re not on the first list?

[00:41:37] I’m curious your reaction to that. I think we’re going to see a little bit of that in, in this cycle. 

[00:41:42] Bill Russell: [00:41:42] No, I mean, Darren Dworkin poked me in the side that when we had coffee, if like. Hey, did you see that announcement? I’m like, yeah, I saw that announcement. It’s easy to do it. I, my, my comment was it’s easy to do it through Apple.

[00:41:53] I’m trying to, I’m trying to expose the entire health record. You’re I mean, take the easy way anyway. 

[00:42:00] [00:42:00] Aneesh Chopra: [00:42:00] Hey, that’s funny itself, but, in truthful kind of tender, I had more CEOs call me that said I’ve wanted to do this for a while in these, but I couldn’t get political motivation. But now my board is calling my CEO, why are we not on the list?

[00:42:19] And I’m getting questions by people who otherwise have been, not that excited about this to say, Oh, that’s what this is. Let’s go. So I had that,  call me that said. I’ve always wanted to, but I couldn’t get the political muscle internally to do it. Now I have the freedom and that’s really opened up a lot of the, doors.

[00:42:38] And I will friendly amendment to your comment about Apple because Apple chose to require the fire Argonaut edition DST to, for the audience members who follow the math. It meant that if, any institution went live with Apple, They are automatically capable of connecting to app number two, three, four, and five without [00:43:00] special effort.

[00:43:00] So there is something about, I do appreciate Apple’s Apple and I’m an Apple fan boy, but this, the decision to go on standards did benefit the it’s a rising tide lifting all boats. All right. 

[00:43:13] Bill Russell: [00:43:13] As CIO, I need to pepper you with some questions here. So, I’m a little concerned about getting sideways sideways with my EHR vendor.

[00:43:20] It’s not like I can switch. So, is there a chance I get sideways with my EHR vendor and what kind of air cover do I have if I decide to be one of the early adopters and push, 

[00:43:30] Aneesh Chopra: [00:43:30] I believe the, conversation is going to be a three way conversation and I believe the third person in the conversation will be the health plan.

[00:43:40] So if you’re the CIO, we’re trying to figure out how to release more data. Of course, you’re going to go after the consumer notes thing we just talked about, and I don’t think you’re gonna get EHR pushback. The pushback will be in the more traditional B2B use cases. Note that the CMS rule requires plans.

[00:44:00] [00:43:59] Government sponsored plans to go live a full year before the ONC rules kick in on fire release for. In a weird way, plans will be live on fire at least for before providers. So the tension I think by design is that it’s the plan. That’s going to be requesting the data. So if the CIO is concerned about not going sideways, it really is, is the CIO plus a friendly plan, maybe one, and that you’re engaged in the value based care contract that wants to do data sharing through API APIs.

[00:44:35] That use case is what will unlock. This may be metaphysical or proverbial jam, and the payers will have enough clout to talk through, you know, litigation risk and everything else as it comes to information blocking. So that’s where I would put my time and energy it’s payer provider, combo explicitly using the data for value based [00:45:00] care.

[00:45:00] That’s the use case that will unlock the data. 

[00:45:03] Bill Russell: [00:45:03] All right. So how many, so. My team’s telling me, Hey, no Moss, you’re killing me. I’ve too many priorities. We’re in the middle of COVID. There’s not enough time. They haven’t given us, you know, the, the reprieve isn’t long enough. You tell me what the case is for not just taking the EHR provider called and said, Hey, just click this button.

[00:45:24] And you’re good. Why not? Why don’t I just take that easy way out. 

[00:45:27] Aneesh Chopra: [00:45:27] COVID, look at the reporting burden on all of your friends on the front lines today. They have to integrate the ELR feed, the CCD feed and ADT feed all for COVID positive patients, and maybe even adding a patient questionnaire in the form of basket order questions that task to meet the August 1st deadline of lab results.

[00:45:54] Reporting from the cares act is so manually intensive and painful. [00:46:00] I believe there’s enough pressure building in the system where a good portion of the market is going to say, I’ll put bodies at the reporting obligations, but I am willing to make an investment so that I come out the other end with more of an automated answer for COVID and it’ll be an acceleration of what I got to do in two years.

[00:46:22] Anyway. So this is the calculation. Do I want to go, all the way 150% on lab results. Reporting for COVID and then start from scratch to meet compliance in two years. Is that, is that a better alternative? That’s the default that’s annoying or can I actually just pull forward the technology upgrades and actually solve both problems at once?

[00:46:47] I think bill watched the next 90 days. We’ll see. A reasonable path that gets us to an accelerated adoption curve. For a good [00:47:00] chunk of the economy. 

[00:47:01] Bill Russell: [00:47:01] It’s that’s interesting. Cause you just took us from focused on the consumer to focus on the transactions that we have to share data between the government to share data between each other, other to share data across the ACO.

[00:47:14] And actually that was my driver. My driver was in Southern California. We couldn’t employ the docs. We had all these different docs, all these different DHRs and they said, alright, we need this reporting. We need this structure for performance. And I was like, Aye. Aye, aye. Back, you know, eight years ago, I’m looking at him going, I can’t do it.

[00:47:32] I, I mean, yes we can, but we were talking about 40 ish, EHR. It was, it was a burden that my team just looked at me and said, we can’t do it. 

[00:47:43] Aneesh Chopra: [00:47:43] So let me leave you with this thought. I know we’re running late, but let me just leave you. This thought the entire state of California is eligible for the primary care first model.

[00:47:53] Which is a multi payer model that requires API APIs in order to participate. [00:48:00] Every one of those primary care doctors is going to have the technical capacity to use fire API APIs, to facilitate a value based care. How many will have the ability to configure those CHRs to run this way? So rather than having to invest in the HIE, that may be a bit of an expensive investment across the 40.

[00:48:21] Imagine a geek squad that would negotiate with each of the EHR is to say, what are you going to do? We’ve got to go live. Now that demand signal in California itself, maybe enough to move some of the ball forward. I think the demand signal is the problem we’ve got to solve for right now. Well 

[00:48:39] Bill Russell: [00:48:39] in the, in the spirit of leaving them wanting, I mean, we could talk for another half hour on this. [00:48:43]but as you said, and you’re right, we have a run run against our time, Aneesh, always, always a pleasure to have you here and look forward to maybe having you back in the, in the spring. I’m sure a lot will have happened by then. 

[00:48:55] Aneesh Chopra: [00:48:55] Thank you, Bill. Appreciate it. Love your show. And I love what you’ve done for the country. [00:48:59] So thank you for your [00:49:00] help. 

[00:49:00] Bill Russell: [00:49:00] Thank you.