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 Welcome to this Week in Health It Where we amplify Great Thinking to Propel Healthcare forward today, anise Chopra, the first CTO of the federal government and president and co-founder of Care Journey, a healthcare analytics. Company is in for a wide ranging discussion on 21st century careers interoperability and what it's like to work in the White House.

My name is Bill Russell Healthcare, CIO, coach and creator of this Week in Health. It a set of podcast videos and collaboration events dedicated to developing the next generation of health leaders. This episode and every episode since we started the C Ovid 19 series has been sponsored by Sirius Healthcare.

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Uh, good morning Anish. Welcome back to the show. Thank you, bill. Pleasure to see you again. I, I'm looking forward to this conversation, but let, let give the, 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, but you also wear a couple more hats, right?

Karen Alliance, the Biden Cancer Initiative among others. Bottom line, you like to like to stay busy. We have a lot of work to do to make healthcare better, bill, we gotta do it. Yeah, absolutely. Oh, where have you been spending a majority of your time over say the last couple of months? So, 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 have felt the same way. I wanna do something. I wanna be helpful. And so we kind of dove in, uh, feet first on where we thought we could make a difference.

And so I, 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, of course, a challenge with, uh, work-life balance. But that's a whole different subject for a different podcast.

I'm excited we have, so I have a little, uh, a new format for this fall. We're gonna do a little longer conversation, so it, it's not gonna be more the q and a session, it's gonna be more, I don't know, just a back and forth natural conversation. So, sure. Uh, here's how this is gonna flow. So you, you and I used to do this when I was CIO.

You'd fly into town or we'd see each other, we'd grab a. Table at a restaurant and, uh, you'd talk about what was coming down the pike in terms of, of regs and, and movement specifically around interop, usually around interoperability. And then you and I would come up with a plan for how our health system could really leverage that to, to really move the needle forward.

Not just comply, but really do something, do something exciting. I mean, these, these things provide A-C-I-O-A platform. To have conversations and to, and to move things forward. And, and I used to love those conversations. So people, uh, for this show, they're gonna get a chance to, to sit in on one of those conversations and see, see, uh, what we used to do way back in the day.

So, but before we, before we get there. And that, and that's what people are tuned in for. But before we get there, I, I wanna, I wanna delve into, to, to one thing here. So my, my youngest, uh, daughter goes to Baylor. And, you know, she came home just like everybody else and has studied for a semester at home. 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. Such a phenomenal show. It was so well done. And so, and it's also a great opportunity to, to discuss issues with your kids and talk about how government works and all those things. Great time watching the. You were there. So I'm gonna ask some questions on her behalf. The first being, you know, what's the coolest thing about working in the West Wing?

So every morning I would walk into what's called the Roosevelt Room of the West Wing, which is cattycorner from the oval. You see it, uh, 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, 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 to whisper in the ear a thing that needed to get done, 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 big up 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. We pack a lot of substance in a very short period of time. We whipped from international affairs to budget, to economic 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 doing whatever we could to help the country get better. As you know, the recovery, we were in the economic crisis during the time I was there, and so.

Every day had this doom and gloom scenario and this sense that like, okay, we're gonna have to, we're gonna have to take a step forward, uh, together. And, and every single voice needed to be heard and action needed to be taken to be, to be successful. You know, it's interesting, as you described that I'm thinking about our staff meetings and the team was always like, we, we have too many things to cover to fit this into 45 minutes.

But for the federal government, I mean, you're covering everything. Everything. You're covering the world, the budget, the, I mean, you're covering everything. Every, so the president in the West Wing oftentimes will 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 was it sort of like somebody ran it pretty, pretty tight.

Somebody was the scrum master. Yeah. So to be clear, president Obama himself would not be in these daily huddles. This is not the best use of the president's time. This is, this is rah Emanuel, or the chief of Staff's time. Yep. Basic construct here, bill. The president's closest advisors would, and that often involved his communication strategy, legal counsel, chief of staff, you know, just, just three or four core advisors.

I was, I was a report, I reported to the president, but I was more that extended 25 to 35 group. And so the, they were largely focused on sharing the president's priorities for the day. Hearing are the things we've missed in the president's priorities that our respective uni corners of the universe 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 anyway. I hope I don't like potentially, uh, 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. Announcements, some, some to sort of a, a, a project that were getting kicked off or motivating that needed to be discussed in those settings.

So it was not a brainstorming session about the future of the world, it was a very specific set of actions that had to be taken and reactions to fulfill. Last two questions. Just, uh, I, I really have to ask, you know, the show sort of depicts first year, uh, incredibly hard. You, 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, a mess in terms of the economy. And so the first year's 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 is an election year. I mean, that's how they depicted on the West Wing. Is that, that, is that pretty much feel like what happened? Well, I would say this is important if you separate politics from policy. You would have a different view about the experience.

And so from a political lens, that first year of stumbles are often things that are policy misstatements or communications flubs or some something that captures the media attention. Let's call that the New York Times, Washington, meaning what you see and read about and the fighting back 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.

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 observed like from the outside healthcare 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.

We saw much more of the collaborative 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, in, in the West Wing. I, I would say having left before the, the, the demise of healthcare.gov, Todd Park, my successor would've had a different experience after that became front page news every single day.

But, but by and large, the, the, the bulk of the work we had done was, was sort of positive, bipartisan, you know, and that's, that's a great transition right there. 'cause, you know, he, healthcare doesn't really come up much in the show itself, in, 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, the vernacular.

You know, when I would say to my parents, you know, secretary Azar. I don't, I don't know who these people are, but the reality is that, you know, 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. But how do you think the pandemic has really changed those roles?

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.

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 and we wait for that once in a generation opportunity to get the Affordable Care Act or the, you know, annual absolute knock.

Him Soum fight. On the physician pay. Back then it was the, if you remember, we, we used to the doc fix every year. You know, Congress would sort of, you know, statutorily say, we're gonna cut doctor pay 20% 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.

And no obvious area that captures the imagination more than telehealth. So imagine the world pre covid. Minus part of our reimbursement model. You had to be very, cases would fund but wasn't, and you've. The Livongo Teladoc merger at 18 and a half. Billion disclosure, I work with Livongo. They're members of Care Journey, and I love Glen Tolman.

The 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. They have a lot of policy levers. They can introduce rules around data sharing for covid lab reporting.

Big, big fight in the, in the, in the Congress and the in the public today about how poorly our data systems collect race and ethnicity information and other inequities. So the executive branch in the pandemic has sort of. Exercised muscles that maybe have always been there 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. We'll get into that as you proceed this discussion. Yeah, and the, the interesting thing is you and I could just talk about the news for the next, you know, 30 minutes and talk about, you know, the HHS. We could go, we could go into Livongo and Teladoc, we could talk telehealth.

But I, I wanna focus in on something that you're passionate about and passionate about. And that's really this, this whole idea of interoperability on behalf of.

Better health in 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 with Nico. And, and if, if anyone has a chance to listen to that, that's a great, like. For this, we're gonna 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 as the CTO. So you, you had a, uh, fundamental platform for, as the CTO, where you were not only looking at healthcare, but you were looking at banking, you were looking at, uh, energy, you were looking at 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.

Yeah. And so, and I'll be clear, not me personally alone, right, right. We have an team, a group, a family, but the group, you know, Todd Park, 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 to business transactions with a proxy statement about what's in the best interest of the patient.

And you've gotta go through a lot of hoops to make sure you're doing the right thing. Uh, to that you may share information under these terms and you gotta make sure both sides agree to the terms. In education. There's a program called ferpa, similar to hipaa, same concept. Your student records are sensitive information.

We gotta make sure when that moves around the internet, it's safe and secure. Banking regulations, same thing. Your financial information's 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.

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 could 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? 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.

If we build a technology strategy on a mandated kind of method data, to me, we could conceivably scale, uh, an interoperability strategy that is required to build on the patient's a consenter right, of access. 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.

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. Clinical records from the hospital, my primary care doctor, my specialist. I can aggregate all that information 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 and that applies to the banking industry. I can take my bank account from Chase, JP Morgan Chase and give it to mint.com. I can do this from my smart meter and my energy grid, where I can take my real time meter reading and give it to my solar panel distribution, uh, uh, app so that I can regulate where I get my energy from, at what time for maximizing the, the cost savings and in education.

So any one of these domains are all built on the same principle. Give me my data in a modern standards format that I can use. However I wish as I navigate whatever the regulated industry is. Right? 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. And so there was things that needed to happen because people would look at it and say, Hey, we have mint and, and that works really well and I can get access to my meter data through different devices and those kind of things now.

But I still struggle to get my, uh, complete longitudinal patient record and give us a little bit why, why is that? And how are we gonna, how are we gonna take those next steps? Market failure. Market failure. This is not a technology issue, although there is investment to be made. It's a, uh, a market failure in that for whatever reason, I'm gonna use the banking contrast to healthcare to make this in the extreme.

When we did the Affordable Care Act and 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, the implementation details.

And that once we get the industry to organize themselves around standardizing gate elements, well, of course healthcare is gonna go finish the job. It's like a propeller. Once you spin, it'll self propagate and we can just capture the energy. 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 smart, 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 wanna plug it in for charging.

You don't want her electrical bill to bear the cost of charging your, uh, car. So we needed a data standard, interoperability standard 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, there has not been a single piece of regulation. Forcing the energy sector to develop common data standards. It's all been industry consensus in the banking industry. In Dodd-Frank, we similarly said the consumer has the right, in this case, buy APIs to aggregate their data. There's never been a regulation needed.

Because the banking industry got its act together, self-organized and built the standards by which the mint dot coms of the world could connect to the, uh, banks all within a regulated context. 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 years? It's because, uh, yeah, we, you know, we don't, we don't tend to self. The, the way you, you talk about, we tend to, I, I remember sitting across from another CIO and I said, Hey, and this was something simple, right?

So we had, uh, you know, we had health information exchange in, in Southern California and I sat across from em, I said, Hey, we'd like to share our data through this HIE and the CIO said, that's great, we don't wanna share our data with you. And I'm like, and I'm not reveal who that was because, but to be honest with you, that point in history.

That was well within their prerogative to say, yeah, it's not in our best interest to give you our, our patient data. You guys can then go after our patients. We don't want that. And, and, and that's why you see the need, the, the, the, what you've just said is why Cima Varma said at HIMSS a year and a half ago when we were still meeting in person, that effectively, and I'm 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 reg, not anti-regulation, but a, you know, a deregulatory agency leader to want to impose some of the strictest and boldest regulations on interoperability.

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, with, with the, uh, Louisiana purchase.

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 execute in the next 12 months or 24 months, depending on if you're a plan or a provider that's gotta hit all these milestones. But in the grand scheme of a decade long effort, we underdelivered in many ways and we're having to pay the piper now because of that judgment that we couldn't get.

The industry is self-organized. My my opinion, so Anisha, there's really two things here, right? So there's, there's, uh, 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.

Those kind 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, uh, technology to make that happen is this interoperability framework. So it's, it's really both and isn't it?

It is a friendly amendment, I would say. The value-based care as a way to deliver, uh, the cost objectives while retaining and boosting quality. That still, in my view, is a religious movement. Oh, it is? Okay. It meaning everybody believes it is. 'cause on paper it is. We have waste in the system. We have fragmentation.

If we coordinated, we could remove waste. The paper argument for value-based care is unequivocal. The actual results. Are modest, we have to do more. And you either are gonna double down on the religion or you're gonna say, we need something else. And so you do see political arguments to say, eh, the heck with this.

Let's put healthcare on a budget. You figure it out. We're not gonna go to value-based care. We've thoughtfully micromanaged a quality metric and a reimbursement formula and a risk adjustment. Man, no, we're gonna cap rates Medicare for all, or we're gonna cap rates, uh, Medicaid block grant. Take your political party idea, and those are not value-based care tools, 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 gonna make anyone's healthcare better. It's gonna create all kinds of se. So yes, yes, needed for care, but acknowledge in this podcast. It's not a guarantee that it's the path to success. And, 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, I don't live in that world as often as you do, as most CIOs don't live in that world as all as often as you do.

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. A handful of other people from multiple administrations sit on that stage and talk about the consistency of policy around, at least the technology and the interoperability over the course of almost two.

And the reality is we need to engage consumers. And as a consumer, I can't get to my data. You know, I, I, I can't hire anyone other than the health system I'm currently seeing or the payer I'm currently seeing. I, I don't really have choice. I don't have trans, there's no transparency in the, in the transactions at all.

And, 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 really focus in as ACIO and say, look, I, I think it's not only good, good policy to have a good interoperability framework.

So when I sit across from ACIO and they say, well, I can, I can take a compliance mindset. Well, you.

Embrace and champion this because we could take this a lot further. So let, let's go down that path a little bit. What, you know. So now we're, we're sort of being 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.

Law is that the data sharing shall occur without special effort. Think about every HL seven interface you had to launch for a specific project to connect to the HIE, to connect to a third party app, to connect to a whatever health plan. 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.

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, 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. So Congress made it very clear that gave the office of the national coordinator and the CMS administrator, all the foundation they needed to state the following. We are gonna tackle technical and non-technical.

It's funny, an 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. So the analogy would be in cloud computing. You've gotta have data centers on soil.

Well, if you've got a UA based cloud company, they're not gonna 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. But the good news is we now have a very clear recipe from the TE Act, our pace.

For achieving the vision of the law of all data to all stakeholders without special effort is constrained to the pace of standards consensus. If six CIOs in a room said, this is how we're gonna communicate this person's homelessness status, we could reach consensus and scale it to every community in the country because the Cures Act gives us that power.

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 wanna make progress, and even if the neighbors and friends make progress at a slightly faster space pace than the rest of the industry. Because of the law, we have the authority to take that idea and to make it accessible.

And there's no single provision more obviously central to this than how we got the bulk fire requirement as part of the ONC rules. And we may get into that as a technical matter, uh, if you wish. Yeah. So I mean, the foundation for 21st Century Cures patients at the center, so I can request my information at no special effort, which is what you said.

It's, it's interesting 'cause some of the pushback came from EHR providers. Some of the pushback came from health systems, and so there needs to be protections in there. Almost. Not protection. Well, maybe it is protections that's a great to, to, to, to make sure that they, they, they don't interfere. Right. So there's penalties for information blocking, but there's, there's also this idea that, that.

They can't. And that's, that's, that's this whole idea. And you've talked about this as net neutrality. Uh, can you cover that concept a little bit? Yeah, that's a great point. So, so this is the, and net neutrality is a principle that stake, that scales the patient access to the B two B use cases. So Bill, this is gonna take a little bit of, uh, lemme take a minute to explain the context.

If I have to, let me take a step back. Every EHR 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. 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, to essentially copy uh, what they've done.

And that's against the spirit of the American economy. And I endorse. We all build businesses that have value and we should defend our 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.

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.

And I think the industry's 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, the cost of delivering that has to be free to the patient. But if you're gonna make that same feed available to health plans, pharma, whomever, you can only charge them this.

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 an a little bit of dollars to get you to get access to my data, but oh my goodness, Optum, you're a bajillion 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, and this is the most important point.

While each vendor is subject to their own net neutrality, we're gonna witness, some are gonna charge a heck of a lot more than others. I can't wait. Fees are disclosed this fall. I can't wait to see the fee structure between vendor A, vendor B, vendor C I'm, it's gonna be, it's gonna be fascinating Negotiating skills.

My point is in net neutrality, it's more than we get net neutrality plus. They have to treat everybody equally. But if you are the hospital and you don't wanna impose those fees on your trading partners 'cause you think they're too high, I can decouple that step away from the vendor into another party that I can run myself and maybe bring down those costs if I believe they are.

They're 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 blue develop a a, a fire based commitment at the Blue Button Developer Conference.

They may be the lower cost 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 others actually work in a business model that is about move, making value out of the data in, in its use as opposed to the value of selling the data, if you will, through the transaction.

All right. So I wanna hit on something before. I'm gonna go into full blown skeptic, 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. Uh, heart and Clear Sense. There's others out there.

There's Innova, there's, well, even Nico's, uh, redox. Because they, they're, they're already reaching into the EHR, they're already providing a set of APIs. They, they could create those kind of things so that tho those, those platforms exist. But how do those platforms get access to the proprietary data? Or do they rely on the open data set?

That, that that's what they're gonna operate from? So this is where the regulations will meet. Lawsuits, re regulations meet litigation. So say, let's just take an example, 'cause maybe it's the simplest use case. Let's say I want to deliver clinical notes. I'm an open, you're an open notes guy if I'm not mistaken.

But, but let, let's assume you wanna make clinical notes available to patients and the regulations say that that data class must be accessible. Otherwise, you're 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 wanna make the notes available, you've signed on to OpenNotes.

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, uh, and the apps they trust. I can do that maybe in December, right when the rules kick in.

How will the market respond? Will the vendors say, no, no, no, no, no. Wait until we ship R 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. If there are lawsuits, I don't hope that there will be.

I think we're gonna 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, uh, burden. And, and, and we should be able to reach consensus on how to accomplish people that wanna go fast. So I, 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.

Is that what we're seeing? Yes. So now that the rules are on the books, now you're gonna see the market decide. Do I wanna be the first in my community to go live and, and maybe even champion that as a value add? Or do I wanna 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.

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 12, 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?

I'm curious your reaction to that. I, I think we're gonna see a little bit of that. I. In this cycle? Uh, no. I mean, Darren Dorchen poked me in the side that when we had coffee of like, Hey, did you see that announcement? I'm like, yeah, I saw that announcement. It's, it's easy to do it. And my, my comment was, it's easy to do it through Apple.

I'm trying to, I'm trying to expose the entire health record. You're, I mean, take the easy way. Anyway, we, I, that's funny itself, but in truthful, uh, kind of candor. I had more CIOs call me that said. I've wanted to do this for a while, Anish, but I couldn't get political motivation. But now my board is calling my CEO.

Why are we not on the list? 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 CIOs 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 and I will friendly amendment to your comment about Apple, because Apple chose to require the Fire Argonaut edition DS TU two.

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 2, 3, 4, and five without special effort. 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.

As as CIOI need to pepper you with some questions here. So I'm a little concerned about getting sideways with sideways with my EHR vendor. 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 forward?

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. So if you're the CIO and you're trying to figure out how to release more data, of course you're gonna 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 B two B use cases. Note that the CMS rule requires plans. Government sponsored plans to go live a full year before the ONC rules kick in on fire release four. In a weird way, plans will be live on fire, release four before providers.

So the tension I think, by design is that it's the plan that's gonna be requesting the data. So if the CIO is concerned about not going sideways, it really is the CIO plus a friendly plan. Maybe one that you're engaged in the value-based care contract that wants to do data sharing through APIs. That use case is what will unlock.

This maybe metaphysical or proverbial jam. And, uh, 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 care.

That's the case that.

My team's telling me, Hey, no MAs, you're killing me. I have too many priorities. We're in the middle of Covid. There's not enough time. They haven't given us. You know, the, the, the reprieve isn't long enough. Uh, you tell me what the case is for not just taking the EHR provider called and said, Hey, just click this button and you're good.

Why don't, why don't I just take that easy way out? 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 ask on order questions.

That task to meet the August 1st deadline of lab results. Reporting from the CARES Act is so manually intensive and painful. I believe there's enough pressure building in the system where a good portion of the market is gonna 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 C-O-V-I-D and it'll be an acceleration of what I gotta do in two years anyway, so this is the calculation.

Do I wanna go all the way, 150% on lab results reporting for covid and then start from scratch to meet compliance in in two years? Is that, is that a better alternative? That's the default, like that's annoying? Or can I actually just pull forward the technology upgrades and actually solve both problems at once?

I think Bill, watch the next 90 days, we'll see. A reasonable path that gets us to an accelerated adoption curve. For a good chunk of the economy. It's it. That's interesting 'cause you just took us from focused on the consumer to focused on the transactions that we have to share data between the government to share data between each other to share data across the ACO.

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 EHRs and they said, alright, we need this reporting, we need this, uh, structure for performance. And I. I back, you know, eight years ago. I'm looking at 'em going, I can't do it.

I, I, I mean, yes we can, but we were talking about 40 ish EHRs. It was, it was a burden that my team just looked at me and said, we can't do it. So let, 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.

Which is a multi-payer model that requires APIs in order to participate, every one of those primary care doctors is gonna have the technical capacity to use fire APIs to facilitate, uh, value-based care. How many will have the ability to configure those EHRs to run this way? So rather than having to invest in the IE that may be a bit of an expensive investment across.

Imagine a geek squad that would negotiate with each of the EHRs to say, whatcha gonna do? We gotta go live. Now, that demand signal in California itself may be enough to move some of the ball forward. I, I think the demand signal is the problem we gotta solve for right now. Well in the, in the spirit of leaving them wanting, I mean, we could talk for another half hour on this, but as you said, and you're right, we have, uh, run, run against our time.

Anish always, always, uh, a pleasure to have you here. Look forward to maybe having you back in the, in the spring. I'm sure a lot will have happened by then. Thank you, bill. Appreciate it. Love your show and I love what you've done for the country, so thank you for your help. Thank you. That's all for this week.

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