financial resources through the HITECH Act, CMMI (Centers for. Medicare and Medicaid Innovation) and ONC's Beacon Commu- nities grant program are ...
Healthcare 2 (2014) 76–77
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Interview
Interview with Aneesh Chopra, M.P.P. Khin-Kyemon Aung, Leah Marcotte, Jon Duke art ic l e i nf o Article history: Received 28 December 2013 Accepted 28 December 2013
Aneesh Chopra served as the first U.S. Chief Technology Officer from 2009 to 2012 and prior to that was the Virginia Secretary of Technology. He left the Obama administration with an interest in driving change at the state level beginning with payment reform. In 2013, he ran for Lieutenant Governor of Virginia and co-founded the company Hunch Analytics, which analyzes both private and public data to help inform decisions that maximize productivity in health care and other regulated sectors. He received his Bachelor’s degree from the Johns Hopkins University and his M.P.P. from the Kennedy School at Harvard University. Health Care: During your tenure as the U.S. Chief Technology Officer, you promoted public–private cooperation in health IT innovation through the Community Health Data Initiative and other programs. Blue Button Initiative is often cited as an example of a government initiative leveraged to stimulate private sector innovations. Has this been an effective model for public–private partnerships? Aneesh Chopra: I think it’s important to understand that there are different models and a better understanding of each might help assess their effectiveness. We’ve organized three types of public-private partnerships:. first is “one to many” or what Tim O’Reilly calls “government as a platform”. In that context, we’ve simply published government data and let anyone use it without financial or intellectual property constraint; we’ve lowered the barriers to entry and actively publicized that this information, much of which had been previously available but perhaps not as widely known, was accessible. My successor, Todd Park, rightly points out that the evangelizing of this data asset is probably the centerpiece of the resulting success of the Community Health Data Initiative, measured, in part, by the growing number of products and services fueled by the data. Blue button falls under a second model, which is government as a leader among healthcare delivery and insurance systems. Introduced by the VA, then CMS, and the DOD, Blue Button is a service enabling patients access to their own data in machinereadable form. It has served as a catalyst for private sector replication and is inspiring standards activity to support thirdparty application developers wishing to aid patients in making sense of their own data. In the interim, Blue Button is shifting from 2213-0764/$ - see front matter & 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hjdsi.2013.12.006
a noun to a verb such that not everyone wishing to participate would have to adhere to the formats adopted by the government agencies. That, I think, is what is driving the success of this publicprivate partnership. Until there are widely adopted standards, Blue Button as a verb will continue to enlist a larger coalition of data holders to participate as they can provide data to their own patients in a format that works for them. A third model is built around some of the market failures inhibiting the success of many digital health products and services, mostly around the limitations of our fee-for-service payment system. With new authority under the ACA, and some previous financial resources through the HITECH Act, CMMI (Centers for Medicare and Medicaid Innovation) and ONC’s Beacon Communities grant program are creating the conditions for private sector innovation. What I mean by that is in the Beacon Communities, the aim was to reward community collaboration around achieving clearly defined population health outcomes, without having to micro-manage which products or services would be incorporated in the care delivery system. Rather, it created the initial capital base to serve as a bridge from today’s fee-for-service system and a future fee-for-value model. More exciting for the future is the CMMI authority and experience issuing grants to providers for testing new payment models, and with validated evidence of improvement, the potential to scale what works across the country. This third model is successful if it can “graduate” some of the innovations tested in “petri dish” conditions to new payment models without requiring additional Congressional intervention. HC: What are some new, evolving innovations and technologies that will enable us to do things or move in directions we couldn’t a short time ago? AC: Let me start by saying that I think where the most excitement will take place is at the state level. When I left the CTO role and ran for Lieutenant Governor of Virginia, a significant portion of my platform was to spend the next four years maximizing Virginia’s capacity for innovation in the public and regulated sectors of the economy, most notably in healthcare delivery. The formula was pretty clear: hit the gas pedal on payment reform, ensure that we have the enabling ingredients
K.-K. Aung et al. / Healthcare 2 (2014) 76–77
for new technologies and business processes to be successful, and scale up as aggressively as possible the culture change that is necessary for the care delivery system to deploy best practices. I still believe the greatest opportunity right now is at the state level and the biggest variable that will drive it is the pace at which its providers’ revenue base is derived from pay-for-value contracts. Second, I believe in the notion of a consumer-mediated model of data exchange, and Blue Button is just one manifestation of that. A consumer-mediated model is perhaps the single most important enabling ingredient. I see health information exchange as critical, but the current enterprise level of data sharing processes are slower to move and encumbered with a higher degree of privacy and security regulations than what we might see via a consumermediated model. So I think the next exciting things will be the new business models, start-ups, products and services that marry consumer-mediated model with data analytics. That happens to be an area where I’m personally investing and dedicating my time through Hunch Analytics. Third, if you take a look at the key decisions patients make, starting with their decision to sign up with health insurance products to selecting a primary care provider to resolving a particular acute condition, the quality of those decisions often don’t reflect best practice. That is to say if we track the patient’s journey in a given year, and ask: what health plan design did they have? Did they make the best decision that was available to them a year earlier? My guess is that a lot more folks may look back and say, “I may not have made the right benefit design choice,” or primary care provider selection based on outcomes. So I think there’s a window of opportunity for platforms that empower consumers with better recommendations around the choices they make, from plan selection to provider selection to specific care pathways. That said, I remain bullish that providers are best positioned to offer such a recommendations engine given the existing degree of trust between them. This is a new and exciting terrain. HC: What are effective strategies to increase the rate of uptake of health IT innovation? AC: The number one driver is payment reform in my humble opinion. The faster we get to payment reform, focused on paying for outcomes, the faster we’re going to see real demonstrations and experimentation in new care delivery models. That will inevitably lead to shaking up the delivery system and the supply of technology-enabled services that supports it. There are probably thousands of permutations of technologies and services that are being deployed from telemedicine to personalized messaging and communications to provider and healthcare coordination support. Ultimately determining which of those will be successful will happen if providers start to think of this as essential to their future and not as a sidebar. HC: From a patient perspective, what might drive innovation and adoption? AC: After leaving the White House, I rejoined my old colleagues at The Advisory Board Company where we subsequently launched a patient engagement challenge as part of the Blue Button movement.
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The big insight we had there was if providers ask their patients to participate in these programs, they do so wholeheartedly and with massive adoption rates. For me, the idea of an individual consumer empowered to take over their health care – while inspiring and a worthy vision, is not how the system operates today. I think, in practical terms, patients will still trust their providers. So here’s what we found. Our patient-centered Blue Button challenge was less about the technology and more about understanding adoption. One aspect of our challenge was working with a volunteer network of health systems with primary care networks who were willingly to ask patients for permission to access their Blue Button file (Medicare or VA), because it includes data that is not available to the provider. What we found was that if the provider asked, almost unanimously the patient said yes (although that came after they asked, “what’s a Blue Button file?”). So it may be possible that patients on their own are going to drive this movement; there are certainly a lot of folks betting that that’s the future. I’m a little more skeptical. I still believe, these consumeroriented technologies, if directed by providers or encouraged by providers will absolutely have impact. And that’s why payment reform to me is so critical. It’s not only provider-oriented change or consumer-oriented change; to me, it’s provider change with consumer participation. HC: Finally, where do you hope to see Health IT in 5 years? AC: My number one hope is for consumer-mediated models of data sharing to reach maturity. The way I describe this is by reminding folks that today’s consumers can “mediate” Apple TV access to their Netflix account safely and securely (using OAuth). I see that kind of ease of adoption in using my PHR or cloud-based structure with providers or third-party analytics firms. The single biggest prediction and hope I have is that if a consumer-mediated model for data sharing is simple enough to use and encouraged by providers, it will be the default method for getting at the holy grail which is knowing everything we need to know about the patient condition and the choices they have and decisions they make. Just to give you an example of what I mean by that in the short run, take a look at the rapid impact of mobile. Walgreens processes one prescription per second via their mobile app today. Recently, they announced that they would support Blue Button allowing patients to download their prescription history. How many doctors today have access to that kind of information? If the doctor’s office asked the patient at registration, “would you mind sharing your Blue Button Walgreens file with me,” then that doctor would know exactly when that patient picked up their prescriptions and if they had picked it up (or not) or if they are on meds ordered by colleagues not connected to their practice. That’s the future but it is also possible today. We just haven’t seen as many examples of people building new products and services to derive value out of that scenario (yet). My second biggest prediction is that between 2017 and 2020 the majority of provider revenues will come from contracts that reward value. That’s a bit bolder prediction but is one that I see as inevitable.
