Judy’s Letter

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Bill Russell

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January 27, 2020: For this episode of Tuesday Newsday, we will be focusing on one story that has been evolving all over the internet in the recent past. Judy Faulkner, CEO of Epic, recently wrote an open letter urging patients and Healthcare CEOs to oppose ONC’s proposed rule to make it easier for medical information to be shared. This episode chronicles the letter itself, various articles that have been written on the topic of interoperability, and some of the divisive opinions of patient advocates and other voices in healthcare shared over Twitter. In today’s show we discuss what patients could lose or gain from this decision, the relationship between developers and current healthcare app platforms, and the pro-patient versus the pro-Epic camps in this debate. Critiques on the potentially misguided focus of the debate itself are provided as well. Some recommendations for what the government should do to secure patient empowerment, privacy, and cooperation are also given. In addition, critique and further guidance for Epic’s strategies are presented toward the end of the conversation. This debate forms the frontlines of the battle of interoperability and digital innovation in healthcare. It has been a long time coming to get to this point but it is coming to a head right now and it is going to be interesting to see how it plays out over this election year.

Key Points From This Episode:

  • How Judy Faulkner’s letter to healthcare CEOs challenging ONC’s plan caused a stir.
  • The plan ONC had: to propose a rule that made it easier to share medical health info.
  • Twitter responses accusing Judy Faulkner of contradicting herself.
  • Adam Tanner’s findings revealing Faulkner’s ostensibly pro-patient perspectives on data.
  • The idea that Epic would still profit after releasing this letter if they were already doing so.
  • Different perspectives either supporting or criticizing Epic regarding their use of data.
  • A scathing letter from a patient advocate criticizing the health industry for not caring.
  • Bill’s agreement that lambasting CEOs before understanding legislation is brash.
  • Seema Verma’s framing of the benefits of the CMS rule.
  • Proposed changes to patient access systems listed on the CMS site.
  • Questionable interoperability strategies at Epic.
  • Changes involving lower tax for startups and developers to access App Orchard.
  • Why the apparently consumer-focused strategies of EHR providers are not such.
  • Cons to the data release: unintended consequences due to a poorly worded Act.
  • The idea that the root problem of this whole debate needs to be defined more clearly.
  • Benefits to more open data: patient empowerment and freer economies of care.
  • The reality that there is a cost to this freer data and somebody has to pay for it.
  • Bill’s recommendations for CEOs to stay out of the fight because of its divisiveness.
  • Three issues with Judy’s strategy: timing, poor advice, and its lack of a coalition.
  • Why not to fight the government as a corporation: it takes time and energy.
  • Two main belief camps in the fight: that Epic is either fighting for patients or themselves.
  • What Epic should do to win: win patients over to their strategy.
  • Three strategies for the government to make what Epic is planning safer for patients.
  • The reality that this fight is the frontline of the interoperability debate.

Judy’s Letter

Episode 178: Transcript – January 27, 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.

[0:00:05.5] BR: Welcome to this week in Health IT News where we look at as many stories as we can in 23 minutes or less, that’s going to impact health IT. My name is Bill Russell, healthcare CIO coach and creator of This Week in Health IT. A set of podcasts, videos and collaboration events designed to develop the next generation of health IT leaders. It’s Tuesday news day and there is a ton to talk about.

We normally take the top 10 stories, break them down, I give you my take on it and we go on to the next week. But today, we’re going to look at one topic and one topic only. That is Judy Faulkner, CEO of Epic. Her letter to the healthcare CEOs and presidents and the subsequent response to that letter. Should be interesting. Buckle up, here we go.

This episode is sponsored by Health Lyrics. I coach healthcare leaders and all things health IT. Coaching was instrumental in my success and it is the focus of my work in Health Lyrics. I’ve coached CEOs of health systems, CIOs, startups, CTOs, you name it. If you want to elevate your game in 2020, visit healthlyrics.com to schedule your free consultation.

[EPISODE]

[0:01:06.7] BR: Okay, if you’re ready, here we go. I most of these stories, they originate from Christi Farr and there’s break off stories from there. Christi Farr with CNBC. The first story that sort of broke this thing was Epic’s CEO is urging hospital customers to oppose rules that would make it easier to share medical information, CNBC.

Think about that title alone. Epic CEO, oppose rules to make it easier to share medical information. I mean, it sort of frames it in the tile itself, doesn’t it? Sort of gets you going. There was a significant response to that and then there’s some subsequent stories. We’re going to take a look at Twitter as well. 

What did the letter say? What was in the letter that triggered such an interesting emotional and visceral response? Here it is. Here’s the letter. It’s pretty straight forward. Subject: Your help needed on ONC Interoperability rules. 

Dear CEO/president.

ONC’s Proposed Rule could negatively affect patients and health care organizations. HHS needs to hear from you so they understand how you feel these issues and that it is important. There’s very little time left.

We are concerned that healthcare costs will rise, that care will suffer, and that patients and their family members will lose control of their confidential health information. Please review the attached information, and if you agree with these concerns, join other healthcare CEOs by signing the attached letter to HHS Secretary Alex Azar, and a copy to Director of the Domestic Policy Council Joe Grogan.

[0:02:36.2] We all fully support helping patients have access to their data. Your patients have been able to download their health information since 2010. Your patients have been able to share their health information with anyone in the world that has internet since 2017. Care Everywhere allows you to interoperate with other health systems and was developed years before meaningful use required interoperability. Epic interoperates with thousands of third-party products/apps.

Let’s prevent the unintended consequences of this rule and make sure the final rule is a good one that is modified to help, not harm, healthcare organizations and patients. ONC may finalize the rule the first week of February, so we must get the message to them right away. 

Thanks for your help in this very important matter.

Okay, that’s the letter. Let’s take a look at the Twitter response real quick. To be honest with you, I’m just pulling people that, you know, not just run of the mill, I’m pulling some pretty credible people here. Daniel Kraft MD, been on the show before, “Singularity University has two words for this letter. Epic fail.” John Chamberlain, board chair for Citizen Health, “Epic CEO Judy Faulker says that patient privacy will be negatively impacted. Really? Like it’s not already.”

“What is Epic’s annual revenue from selling de-identified patient data?” Not sure about this one. Not sure that’s the direction I would go with that one John but to be honest with you, you know, they’re worried about patient data. I would have gone in the direction of number of breaches, you go in this direction and I’m not sure this direction’s accurate in the book.

Our bodies, Our Data, Adam Tanner actually interviewed Judy Faulkner and this is what was said, this was like two years ago. “By contrast, Judy Faulkner, the founder of Epic, which does not share data, said she was uneasy about the commercial use of her anonymized information. I would feel fairly uncomfortable about that, Faulkner does believe that scientists should have access to anonymized data to advance medicine without patient consent.”

“But if the data are used for sales and marketing, she thinks patients should be able to call the shots. Personally, if there is, for legitimate research purposes, ‘I would like to see all data accessible,’ she said. ‘Anything other than that, I think is fine if the patient has a say over it.’”

You know, I’m not sure that Epic is making a ton of money. I mean, it’s a private company so we don’t know. I don’t think they are making a ton of money from selling de-identified data. Again, I could be wrong with that. I know that Cosmos was designed to pull that data together for research purposes. I’m not sure the flow of money in that whole transaction. I could do a little research and get back on that but, again, not the direction I would’ve gone in. I’d’ve gone in the Breach direction not in the selling of data. I’m not sure that’s accurate but I do share it to give you an idea of just the –

[0:05:17.9] This was the dog whistle. It brought out everybody who has a problem with Epic to say whatever they wanted to say. Robert West PHD, emeritus professor. “It’s hard to feel sorry for Epic or trust anything they suggest for that matter,” give you an idea. Joe Connelly, founder and CEO of Asana health just re-quotes the quote and I think he’s sort of poking fun at it which is, “Your patients have been able to share their health information with anyone in the world that has Internet since 2017.” It seems like he’s just pulling that out. 

Matthew Holt, Health 2.0 fame says this, “Judy is genuinely, earnestly worried about data being resold. I heard her directly tell Kaiser Permanente that HealthVault would sell their data and should not be trusted. If she was merely self-protecting, why would she release such a dumb letter.” I think that’s fascinating that he said ‘dumb letter’ and I think Matt would want me to share the next section where he describes why he thinks it’s a dumb letter.

“I call this a dumb letter because it’s a rear guard action which wouldn’t actually impact her business. Epic has an API app store. Their FHIR APIs and patient third party access to data was freely available. It would still come from the Epic platform and they’d still make money.”

 A couple of things. First, absolutely agree with. I actually sat at a table where Judy was making this case pretty passionately and I believe she really truly does care about patient privacy.

That would not be out of character to believe that, although I do understand the other people who believe that they’re just creating a deeper and wider moat around their Epic platform so that they keep the competition out. I understand how you can get there.

[0:06:52.2] The second thing, you know, I think if I read the intention of the ONC proposal and the rules that is that Epic would not make money from access to that data. Again, I’m not sure that I agree with the second one because the intention is for data to be accessible via a FHIR API and freely accessible to developers to make that happen.

Frank Matthews, founder of principle of HealthQuant. “The thing I’ve never understood is why hospitals keep buying Epic. Everyone knows that their entire business is built to hoard and control data. The hospital is more complicit in this than we seem to be willing to admit.” Again, just giving you public sentiment on this.

Bray Patrick-Lake, director of strategic partnerships with Evidation, if you don’t know who they are, this is what the statement says. “Our mission is to empower everyone to participate in better health outcomes.” This is a patient advocate group. “Please keep us updated on the hospitals that support Epic’s position. Patients deserve to know.” Interesting. Sounds like they’re willing to hold the health system leaders accountable who signed this. 

On The Healthcare Blog, Grace Cordavano, PHD, another patient advocate, wrote this letter to Ms. Judy Faulkner and Mr. Tommy Thompson.

[0:08:08.6] I apologize. I’m just reading a lot of stuff because there’s just an awful lot of stuff that got released. This is a patient advocate that was wondering if her work was worth it and I’m going to skip a bunch and just get to I think the meat of it.

“After 20 years of advocacy work. When I close my eyes and reflect. I cannot un-see and un-hear what I’ve seen. The people that have died horrible deaths because of cancer with not a spot of dignity left. The parents who fought tirelessly to find hope for a cure or a gift of more time with their dying child, the people who have watched as their parents and grandparents died sometimes slowly, unfathomable deaths from their heart failure, dementia, cancer, diabetes and other morbidities.”

I have to note that this is literally – the title for this is, you know, a letter to Ms. Faulkner and Mr. Tommy Thompson, okay? It’s directly to them. 

“The people who struggle with their own cancer diagnosis while caring for their aging, sick parents and their also disabled and medically complex children. The people who were disabled, who have been denied critical care that they needed, the people living with chronic illnesses. The tears stream down my face as I recall the hundreds and thousands of pleas I’ve been faced with over the last 20 years. Pleas, stories, cries for help that break one’s soul and leave you gutted.”

 

[0:09:21.0] “There is a common denominator here. These people could not get access to their information they needed for the next step in their or their loved one’s care. Information they needed to schedule a second and third opinion appointment. To organize a tumor board, to consider clinical trials, to ask the right questions , to pick the right doctor or hospital, to fight an insurance denial.”

To do a peer to peer or expedited care needed themselves, to make informal decisions about an upcoming surgery or procedure, to prevent medical error from happening, to fight an exorbitant medical bill, to understand their diagnosis and treatment enough to know it wasn’t too early for palliative care. To know that it was time for hospice. This is what information-blocking looks like, boots on the ground.”

Then it goes on, “Thank you Ms. Judy Faulkner, CEO of Epic for your recent letter, urging some of the biggest hospital CEOs and presidents to oppose the proposed rules, to improve interoperability and grant patient access to their information. You have made it crystal clear that you are not aligned with the real world unmet needs and barriers, patients and care partners face daily.”

“Thank you for illustrating what paternalism or looks like in 2020. Thank you Mr. Tommy Thompson, former governor of Wisconsin for your guest column on why the proposed health IT rules would be a detriment to epic and Wisconsin’s economy.”

[0:10:39.0] “You have made it crystal clear that the business priorities of Wisconsin are of greater importance than the legal rights and sanctity and dignity of the lives of all patients of their great country of the United States of America. Thank you for helping me refocus. Thank you for helping me answer the question and address the self-imposed imposter syndrome that can momentarily cloud one’s perception. The answer is, it’s all worth it,” says a patient advocate. 

Wow. Following up from that, Amy Gleeson, “Calling on patient advocates. Anyone interested in signing a patient care giver letter to counter the Epic letter. I would like to have one that is only patient’s caregivers to tell our side of the story.”

Okay, that’s just overwhelmingly the response. One last tweet here. This is from a physician who has been on the show who I greatly respect, Lee Milligan, Asante Health. He stood in the gap, a lot of stuff going in the other direction and he says, “It’s important to read the proposed legislation before lambasting the obvious target of epic CEO Judy Faulkner.”

Christi Farr, “Protecting patient PHI is not a tertiary construct but a legal and moral obligation. Interoperability requires universal standards and agreement on usage.” I think it’s important here because I agree with Lee here and I stood in the gap and you know, again, I think it’s important to understand that – what CMS is proposing. That’s where we’re going to go next, that’s what we’re going to dive in to. 

[0:12:00.5] –what a potential limitation of what they’re proposing for right now and then, you know, determine what the right approach is to actually going about this because he’s not wrong, and they are definitely not wrong. We need to get the patient, the data that they need to be empowered in a digital economy where they can make decisions, they can engage people to help them in their care and so, that sort of frames up the two sides of it.

Okay, why was the letter written? CMS – this is what’s on the CMS website. CMS Advances Interoperability and Patient Access to Health Data Through New Proposals, this is February 11th, 2019 and we covered this in detail last year on the show and we also did a whole episode on interoperability, you can check that out as well. Here’s what administrators Seema Verma said in this frequently asked questions type thing.

“Far too long electronic health information has been stuck in silos and inaccessible for healthcare consumers,” said CMS administrator Seema Verma. “Our proposals help break down existing barriers to important data exchanges needed to empower patients by giving them access to their health data.”

“Touching all aspects of healthcare from patients to providers to payers and researchers are work leverages identified technology and standards to spark new opportunities for industry and researchers while improving healthcare quality for all Americans.”

[0:13:22.7] “We ask that members of the healthcare system join forces to provide patients with safe, secure access to the control over their healthcare data.”

Okay, here are the proposed changes. Number one, patient access through APIs which are Application Programming Interfaces, this is how innovators and Silicon Valley types get access to the patient data.

Health information exchange and care coordination across payers, so they start to include payers in this whole mix which is an important data set that in some cases go untapped, at least you don’t bring these two together very easily. API access to publish provider-directory data. Again, another important data set. Care coordination through trusted exchange framework improving the dual eligible experience by increasing frequency of federal state data exchanges.

Public reporting and prevention of information blocking, provider, digital contact information, revisions to conditions, participation for hospitals and critical access hospitals. And advancing interoperability in innovation models. Okay, you can review these things on the CMS site or you can listen to the whole podcast episode I did on interoperability last year. I go into this in some detail.

You know, the question isn’t really ‘what.’ Both sides are trying to position themselves as advocates for the patient. We, you know, both want to say, “Look, we want that information to be shared. We want empowered – digitally empowered patients, that’s absolutely what we want,” the question comes down to ‘how.’ If you were to pull people in healthcare today and say, “What is Epic’s –

[0:14:50.7] You should try this some time. “What is Epic’s strategy for interoperability?” Most would say to you, “Epic’s strategy for interoperability is to have everybody on Epic.” If you go into a market and say, “Well, we want to make Cerner and Epic talk together,” they’ll say, “Well, the easiest way to do that is to replace Cerner,” or, you know, “We want this to work,” “Well, get them on care connect or community connect.” 

I mean, you get the picture that most people would say, “That’s what it feels like is their strategy.” How is what Epic is doing with Apple which is different from say, Apple and you know – because Apple has an API interface and they have an app store, that’s what Apple is truly set up to do, to promote interoperability. Again, what’s interesting is, both sides would agree that these APIs and app stores is a great approach to empowering the developer community.

However, you know, one side, really charges a tax while the other really doesn’t want any tax to be charged for that data and oddly enough, the one that does not want to charge a tax for access to the health data is the federal government. Very interesting. In October of 2018, this story appeared in Politico following the cost reduction for access to App Orchard. 

Epic has announced a program fee reductions of 33 to 80% for developers participating in App Orchard program, according to sources at the company’s annual developer meeting in Epic’s Verona, Wisconsin headquarters. I’m very happy with the changes said Rick Freeman, CEO of Interopion, whose complaint earlier this year about exorbitant prices for participation and vendor app stores as reported by Politico, may have helped spur the action.

[0:16:28.9] Freeman noted, at the time that the family planning questionnaire app he developed for HHS, office of population health could have cost him up to $750,000 to run on Epic or Cerner for a year. Epic will charge lower fees for most of the 350 companies that participate in the app development program, said App Orchard director of Brett Gann. It will enable early stage startups to enroll in the program with access to Epic’s public API documentation and sandboxes for $100 per year until the apps are ready to be commercially used.

All right, all those things are very welcomed changes, right? We reduce the tax for developers to get access to the data and we also reduce the bar for entry so you had a lot of startups that were – didn’t have a huge revenue stream that were trying to develop new apps and they could not pay whatever the fees were that Epic was going to charge them and they created a much easier barrier of entry.

This $100 per year until they’re ready to be commercial. Is that the only tax? Well, it turns out, there’s a lot of challenges with having a company run app store, right? We see this with Apple from time to time, you know, they change their terms – or YouTube, you know?

They change their terms and now all of a sudden the YouTube developers or the people who create content have to scramble. Apple will change their fees and all of a sudden, these developers have to pay more. Now, Apple is smart enough and Google is sometimes smart enough to be consumer-focused and because they’re consumer focused, they do what’s in the best interest of the consumer.

[0:18:00.3] And that’s really what these EHR providers are trying to portray here, that they are doing what’s in the best interest of the consumers. However, you have to look a little more closely. So you know it turns out there isn’t much in the way of negotiations on the terms and conditions, which also puts something on top of the developers. There is also challenges with how intellectual property is handle through a lot of these app stores. 

And the developers have to weigh being a part of these app stores because they are giving away some access to their intellectual property and when you think about it, there is no other choice. We could say that, “Hey these developers don’t have to do this.” No, they do. If they want to play in this, they have to get access to the data and they have to get back into the workflow. If they have to get access to the data and back to the workflow there’s only one path to do that. 

You have to go through the EHR provider because that is what the health systems have put in place as the interface to get to the doctors and an interface to get to the data. So they have to go through that and it creates a situation like we had back in the day and back in the day, this is going to date me a little bit, but there used to be this old saying that MS Dos isn’t done until Lotus won’t run. 

So Lotus was the predominant spreadsheet back in the day and Microsoft had – they tried to really push Excel and they had these two platforms and they would as the saying goes, MS Dos wasn’t finished until Lotus was broken. So they would roll out MS Dos, which ran every computer known to man and so if you are running Lotus whatever version you had stopped working and Lotus would have to sprint and scramble to rewrite the code to get it to work. So they were constantly patching. 

[0:19:37.9] Well overtime, Microsoft hobbled Lotus so much that many of our listeners have never even heard of Lotus, right? So there is that sort of concern of having a privately owned gateway to health information that you hear patient advocates complaining about and you hear developers complaining about if you talk to them enough. So with some prompting from big tech, let’s be honest here. The federal government has been prompted from big tech. 

You know the Apples, the Amazons, the Googles of the world and Microsofts to say, “Hey, if we free up this health data, we could do some things with it,” which is kind of ironic and interesting but the ONC is proposing a plan to free the data from it’s silos and to share that data through a set of APIs and security and hopefully what will happen is you’ll have the innovation really explode in a lot of different ways to make new ways of receiving care and delivering care possible. 

So no taxation, just looking out for the best interest of the patient. You know what’s wrong with that? What could possibly go wrong? Well, how about an unintended consequences, right? So Healthcare IT news, September 13th, 2019, Could HHS information blocking rule have unintended consequences on data sharing and security? A legal expert who helped write [inaudible 0:20:54] comments on the proposed rules offers an in depth look at the new rights and explains what it could mean for IT info sec leaders. 

And this, Amy Leopard, Bradley Arant, Boult and Cummings – I covered this also when it came out – you know, talks about some of the unintended consequences and I will spare you the long version of the story but essentially what it is, is the verbiage was really unclear in the 21st Century Cures Act and because it was unclear, the burden went to the health systems to deny access to certain data, right? And so if they are going to deny access to certain data they would have to document that and to present a case as to why they were blocking that data.

[0:21:36.7] And there could be some really good reasons for blocking that data. I know what you’re thinking, Healthcare IT News aren’t they own by Hymns and doesn’t have Epic have the largest booth at every year at Hymns? Sure but let’s consider another scenario and I will create this one and I have no money coming to me from Epic. So let’s assume, I was going to say a nation state but nation state doesn’t make sense here. 

Let’s assume a crime family because crime families are in the cyber security hacking business, right? So let’s assume a crime family wants to write an app that provides significant value to the healthcare community and they put it out on the IOS app store or Google Play and my parents download the app of this nefarious actor, okay? They receive real value in some way because these crime families aren’t stupid. 

They know in order for people to download their app, in order for millions of people to download their app they have to provide some value. So they hire some people who write a really good app. I don’t care what it does but it does something really cool that other apps don’t do or don’t do as well. So my parents download it. The crime family of course has access to all sorts of information that will make it easier for them to steal their identity or utilize it for whatever purpose they want, okay? 

So that is a very real possibility, unless we close those gaps and make the rule crystal clear as to how people get certified to access that data, what data they actually have access to, how often that has to be audited, you know, all of those things need to be put in place. So, you know, when you prompt even advocates of the federal plan, they say that there is some details left to work out. So what am I saying? Am I saying we need to have a trusted gatekeeper for that information? 

[0:23:16.6] And that gatekeeper needs to be the EHR provider? Not necessarily, to be honest with you. I am saying we need to define the problem that we want to solve and solve for that problem. You know, the government’s vision is empowered, informed patients with choice. A free market economy and health care. A digitally empowered patient has access to the medical record and share it with whomever they choose. They can choose to get the record and they can have it looked at by their PCP. 

Or they can have it looked at quite frankly by the person next door. They could put it up on their Apple TV and have somebody look at it and go, “Hey, you know I know somebody else with that.” That is really the nature of empowerment. It is up to the consumer to determine who looks at it. It is believed that if every patient has access to their own record, it is going to create this market of vendors who will be willing to step in and provide second opinions in care navigation and digital solutions around the medical record. 

Those can be big players like Google, Amazon and Apple but it could also be small players. So that the Epic vision is really empowered, informed, and protected patients, right? And the key that they are trying to drive home right now is the protection does come with cost. You know you have to have somebody that really cares about the patient and the privacy of their data, which in this case is the EHR provider but it comes down to cost and you have to trust the protector first of all. 

And somebody has to pay the toll because there is the cost to keeping these things going. The benefits is that you lived in a walled garden and you have access to well-orchestrated care experiences with the highest quality possible, right? We want those things. So you have these two competing things and to a certain extent I am torn in that I do not want my parent’s data – I am scared for my parents to have access to their data. 

[0:25:00.2] I know the number of phone calls I get in a day being asked for their social security number, those kinds of things. This is a very real threat that needs to be addressed in the rules that CMS is proposing here. On the other hand, I don’t want people to not have access to their complete longitudinal patient record when they need it most, right? And so since I am torn, I am going to tell both sides here, actually I am going to go three directions here. 

I am going to talk about what the health systems should do, I am going to talk about what Epic should do and I am going to talk about what the government should do and you may or may not like this but – because I am going to act as an arms dealer here and provide both sides with a direction that should really take this. So the first thing is for the health systems. This is a heavy weight fight. This is Ali-Frasier. Sorry I am dating myself again. 

There are going to be punches thrown that would fell the normal average man. I wouldn’t get in the middle of this one. You know it is an election year, the optics on this are horrible. Yes, it protects the patients but, you know, neither side has made their case to the American people. This will become a political issue. Trust me, this will become a political issue. Judy has all but assured with this letter, in an election year this will become a political issue. 

And it is really unclear how this is going to play out but if it is like other issues that are playing out in our country right now it will be split like 50-50 and if it is split 50-50 that means that 50% of your consumers are going to be happy you took your side and 50% are going to be unhappy you took your side. So, my recommendation, if I am talking to my CEO saying, “Should I sign this letter?” my recommendation would be, “No just stay out of the fight.” 

[0:26:37.5] Let’s talk about Epic and Judy. I am going to give three problems that they have and a proposed strategy around it. So the three problems are the timing is awful. This is an election year. It is just an awful time to be bringing this up. You just made it an election issue if it is handled in a certain way. The strategy is ill-advised. As I shared right after UGM that you shouldn’t pick the government as your adversary. It’s just a bad strategy. 

And the third thing is you haven’t built a complete coalition at this point. You haven’t won the hearts and minds of the American people. When I say community hack, they have no idea. When I say Care Everywhere, they have no idea what these things are or what they do for them. So you haven’t built a complete coalition. Health systems might understand what we’re talking about in that case but patients do not. So if Judy were listening to the podcast she would know I strongly recommended that, you know, companies that pick fights with the US Government do not fair very well. 

She can watch In the Mind of Bill Gates. I think it is called In the Mind of Bill Gates or The Mind of Bill Gates, the Netflix special and actually I highly recommend it. It is really fascinating, the transformation he’s made and it really covers the work at the Bill and Linda Gates Foundation. Documentary on Netflix. You know, in addition to the companies is that the business leaders don’t fair really well in these bouts either with the Federal Government it takes up a lot of time, energy. 

It saps you because it plays out differently than you think. The sound bites that are taken are a lot of times taken out of context, you know? So again, I would not have recommended picking this fight but the cat is out of the bag, you picked a fight. So this is a really going to play out in two camps. The first camp is the right thing to do to protect the patient, right? So it is altruistic. Let us make sure at all costs protect the patient and then the other is this is an Epic moat strategy. So self-serving monopolistic and the two camps will form around this. 

[0:28:37.2] So if you want to win on the hill, what you have to do is provide cover for elected officials. You have to create a narrative that the American people are behind, and right now, no one owns this narrative at the patient level. They just don’t. Most patients have no idea this fight is even going on yet, but once they do, they will have to decide based on the information that’s in front of them and nobody has made this case to the patient and to the American people. 

My recommendation to Epic is a massive targeted marketing campaign in partnership with your clients, right? So go into those major markets with your health systems, even joint marketing dollars and start telling your story and, you know, why is Epic’s plan better for patients? You know, my mom texted me last night. I wish I had this text. My mom texted me last night, “Hey, it turns out I can go anywhere in the country with my patient record.” 

She is a patient at a Health System that is an Epic health system and she goes, “It turns out I can go anywhere in the country and my medical record follows me,” right? So that is the narrative that she’s heard and that’s the kind of thing that you need to happen exponentially. You need everybody’s mom texting them saying, “Hey I can now go anywhere with this record.” Now I didn’t have the heart to tell my mom it is not true. 

She can go anywhere that has Epic so when she goes to Florida for a vacation, she is going to have to find an Epic shop to go visit as oppose to wherever the ambulance happen to take her. Anyway, which isn’t entirely true with the Care Everywhere platform. You get a onetime use but you can’t bring that data – anyway. Long story. I am getting into the weeds. 

[0:30:20.5] So that is what Epic should do. My recommendation, massive targeted marketing campaign across the US. You have to win this narrative. Government, this is for sector ASR, Seema Verma, and company. You have to fix the perceived security and privacy questions that people are having around this. This is far and away the most popular approach to solving this, is what you are proposing. This is easy to understand, easy to get out there and easy narrative to win but you have to plug that gap so start there. 

Number two, you have to seize the high ground that was just gifted to you by Judy. Judy picked a bad year to do this. She picked a bad enemy to fight in the Federal Government. A lot of money, a lot of lawyers, bad enemy to fight. So seize the high ground and the third thing is – and this is just a last stitch effort and I am not even sure I like even saying this but consider trust busting, seriously. Trust busting the EHR providers for the good of the patient. 

From this perspective, I would split them at the point that makes them incented to love interoperability. So you take Epic’s business of the EHR and you split that from any ancilliary applications that use that data. So Cosmos now becomes a separate company and Apple Orchard becomes a separate company and whatever. So anything that Epic’s thinking of doing on top of that data has to become a separate company. Same thing with Cerner, separate company. 

So you know Healthy Intent, separate company. So they are incented and any time they give access to Healthy Intent or Cosmos or anybody else, they have to provide those same set of APIs to every organization in the country, right? So that’s where I would split them out. Split them at the point that makes them incented to love interoperability and to build out the connections that the community would benefit from. 

[0:32:12.8] So why, why this strategy? You know the first thing is you are not going to look good if you don’t protect my parents and I can’t support you if you are not going to protect my parents and their health record, let alone my kids and their health record. Number two, same message I just gave Epic and Judy, which is, if you are taking the message to the patients, you have to win the hearts and minds of the people and if you do, you win the war. 

Whoever wins the hearts and minds of the people who frames this debate with the people, wins, and, you know, you have a very populist president who is – somehow connects with tons of people through Twitter and you know I would take advantage of every aspect you have because you are not going to do some massive marketing campaign at every city but you do have the bully pulpit on this one. So gain the messaging high ground. 

And then the last thing is again, I hate the concept of trust busting but there comes a time where you have to use every tool in your bag to protect the health of the American people and if you firmly believe, which I have heard Seema Verma now speak in public many times and several times I’ve sat pretty close in the front row and I believe she firmly believes this, that this data siloing is hurting patients and holding progress back, then you have to consider every tool in your bag. 

This is the frontlines of the battle of interoperability and digital innovation. This has been a long time coming to get to this point but it is really coming to a head right now as we speak and it is going to be interesting to play out over this election year, over 2020. I think we are finally at a point where the hard questions are going to come to light. We are going to answer those hard questions. We are going to be held accountable by the public on how we answer that and which side we take on this debate and it is going to be a wild 2020 and I am looking forward to it. 

[END OF EPISODE]

[0:34:00.2] BR: That is all for this week. Special thanks to our sponsors, VMware, StarBridge Advisers, Galen Healthcare, and Health Lyrics for choosing to invest in developing the next generation of health leaders. The show is a production of This Week in Health IT. For more great content, you can check out the website at thisweekhealth.com or the YouTube channel. If you want to support the show, the best way to do that is to share with a peer. Send an email to someone, let them know that you are listening to the show and that you are getting something out of it. 

We’ll be back again on Friday with another interview with an industry influencer. Thanks for listening. That is all for now.

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