Portal de Periódicos da CAPES

Catalysts for Change: A Conversation with America's First CTO

2015; Mary Ann Liebert, Inc.; Volume: 1; Issue: 1 Linguagem: Inglês

10.1089/heat.2015.29008-skg

2639-4340

Aneesh Chopra, Stephen K. Klasko, Neil Gomes,

Pharmaceutical industry and healthcare

Healthcare TransformationVol. 1, No. 1 Open AccessCatalysts for Change: A Conversation with America's First CTOAneesh Chopra, Stephen K. Klasko, and Neil GomesAneesh ChopraFormer (and First) U.S. CTO, Executive Office of the President, White House; and Hunch Analytics, Cofounder, EVP, Arlington, Virginia.Search for more papers by this author, Stephen K. KlaskoEditor-in-Chief, Healthcare Transformation; President, Thomas Jefferson University; and CEO, Jefferson Health.Search for more papers by this author, and Neil GomesVice President, Technology Innovation and Consumer Experience, Thomas Jefferson University and Jefferson Health.Search for more papers by this authorPublished Online:10 Dec 2015https://doi.org/10.1089/heat.2015.29008-skgAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail A decade ago, the words “hi-tech” and “government” used in a single sentence may have been the perfect image of an oxymoron. Not anymore. Not since Aneesh Chopra was appointed by President Barack Obama as the first chief technology officer of the United States.As chronicled in his book, Innovative State, Aneesh made it his personal goal upon appointment to leverage the transformative power of technology, crowdsourcing, start-up thinking, and open standards to make government hi-tech, collaborative, innovative, agile, and simply … cool.“In your book Innovative State, you chronicle the transformative power of technology as it has gradually brought about change in government over the ages.”Healthcare has traversed a timeline very similar to government and could use similar thinking to catapult it into the future. It's about time we too made that transition—about time we bring the “cool” into healthcare. And here's how. In this interview, Healthcare Transformation's Editor-in-Chief, Dr. Stephen K. Klasko, and Associate Editor Neil Gomes find bold, transformative advice from Aneesh Chopra, who has his sights focused clearly on healthcare as his next frontier for change.Dr. Klasko:Aneesh, thank you for joining us to talk about how technology can drive transformation. In your book Innovative State, you chronicle the transformative power of technology as it has gradually brought about change in government over the ages. In fact, some people think there are parts of government that are actually cool for the first time.Mr. Chopra:I would agree.Dr. Klasko:And I think one of the things that we saw from the outside is how you focused innovative thinkers in industry on collaboratively solving the problems of government. Healthcare is traversing the same timeline, but is a little behind. As you think about our transition and how we bring some of that cool into healthcare, what can be a major catalyst for this change? What is the shock? And do you see outside folks—governments, providers, payers, pick anybody—playing a role in the journey to harmonize healthcare and develop a cure for itself?“In our case, President Obama made a pretty bold statement on his first full day in office that he was going to shift the default setting of government from closed to open.”Mr. Chopra:Thank you for the question. I would start by saying that the ultimate catalyst for change is the CEO, the executive. In our case, President Obama made a pretty bold statement on his first full day in office that he was going to shift the default setting of government from closed to open. He referenced the role that a chief technology officer would play to help execute the vision that he put forward. But make no mistake, it was his vision that he wanted to basically close the innovation gap.His particular perspective in terms of a catalyst for change was that the country had a lot of problems, and we had to expand the toolkit in order to meet those problems. One of those tools was going to be the role that technology, data, and innovation could play as a complement to the more traditional tools that had been made available by prior presidents around new regulations, new investments, and the like.The challenge, or the opportunity, when it comes to this catalyst is you need to have the leadership commitment up front, but then you also have to have the management capacity to execute. And so the combination of the two is where we saw the greatest impact.Clearly, in healthcare, we are facing the same leadership moment. There are those CEOs who are looking to build a future that focuses on value and are looking to their boards and proclaiming that they want to be leaders in a value-based care delivery model. Those are the leaders who are making a call to action built around that new operating model. But there are also leaders who are somewhat contrarian: “I see this potential future. I do not know that it will pan out. Instead I want to take my organization toward continued operational excellence within the current fee-for-service environment, betting that it might continue.”In both cases, the catalyst for change is that as the leader declares the vision that he or she wants, there are roles for technology, data, and innovation to help accelerate that vision on either front. Either can be supported by technology. Obviously I am much more focused on organizations that are diving into value.“I am much more focused on organizations that are diving into value.”Aneesh Chopra and family with President Obama in the Oval Office.Dr. Klasko:You had the CEO taking a leadership stand, in this case, the CEO of the country, saying, “This is what we are about.” I have to believe that even though people worked for him, that there were people rolling their eyes and saying, “You know, hey, I have been in government for 20 years. I am not going to do this.” Did you find that, or … ?Mr. Chopra:Yes, of course.Dr. Klasko:Did everybody just say, “Oh, Aneesh, you know, anything you say.”Mr. Chopra:No. That is an exceptional point, because you are right, declarations are only as good as the voice that presents them. We had an expression called the B Team. You know, “I will be here when you leave. I was here before you got here.” Basically, the B Team was the sort of stereotypical view of an individual that might want to wait out this particular wave of leadership. Every organization has the proverbial B Team.I would say that you engage the B Team with a management approach to close the gap. On open data, our execution plan called for every federal agency to open up at least three high-value data sets for the American people to access in machine-readable form within 45 days. And that combination of the president declaring, “This is the new approach to problem-solving,” combined with a very practical approach that had people deliver results in near–real time helped to shock the system.And I will just give you one small, little anecdote. The CIA, when they were told to disclose a data set in machine-readable form, the first high-value data set that they put forward was the menu for the cafeteria in the CIA—which, by the way, turned out to be one of the more popular data sets.Dr. Klasko:There are a lot of parallels regarding inertia between longstanding federal employees reporting to a president they know is only going to be there for eight years and tenured faculty for life reporting to university presidents that have an average tenure of about three or four years.Mr. Chopra:Yeah, yeah. Management techniques of carrots, sticks, and transparency all were in play during our tenure. We asked for the carrot, which is,he will honor you. President Obama, you know, in his cabinet meetings would call out cabinet secretaries who oversaw innovative programs, even if they were just getting started and had modest impacts but were in the right direction. They got shout-outs by the president and rewarded.We held agencies accountable through mandates like the three high-value data sets. And on transparency, we graded each of the agencies on their implementation plans, and we put that on a public website so people could see how well we were internally grading the agencies.Mr. Gomes:As you have made this transition from government to industry, you must have had several choices for what you could do after that, but you picked healthcare and healthcare systems. Can you explain why you chose the path of bringing about change in healthcare systems via technology, data, intelligent analytics?“Today is the best time to be a healthcare entrepreneur in America.”Mr. Chopra:Thank you very much. My passion for healthcare predates my role in government. My first job out of college was as a banker at Morgan Stanley, where my colleagues took Netscape public, and I was enamored at the possibilities of the Internet and what it might mean for healthcare. My subsequent graduate thesis examined the lessons of Internet-based technologies in academic medical centers, writing about the case studies at Beth Israel Deaconess and some of the work that had been done to embrace Internet-based technology to virtually connect providers.I have been very passionate about where and how healthcare could advance by building on the Internet, and I just simply pivoted my role over time. I spent a near-decade at the Advisory Board Company, wrote our first major study on the Internet for our membership base, as well as serving as Virginia's secretary of technology with then-governor Tim Kaine, now senator. During my interview, he specifically focused on my passion for healthcare IT and that the moment was right for the public, private, nonprofit sectors, federal, state, and local to collaborate to modernize the system and the infrastructure.He would later ask me to co-lead that effort with our then Health Secretary, later CMS Administrator, Marilyn Tavenner. This had been a priority. When the President hired me as CTO, he encouraged me to make healthcare one of those areas of focus. And so it was not that high of a leap to suggest that the foundation of what we were doing in Washington might have implications in the private sector.A big thrust of our efforts in government was to open up data sets held by the government. The holy grail for sure had been the linked Medicare claims data sets, which are a window on the performance of the healthcare system for 40-plus million Americans. We can see what patients, what conditions they have, what doctors they have seen, where they have navigated in and out of various networks, and how they were treated; all of that information is essentially locked into this database, with very few entrepreneurs and innovators having access to it for purposes of making the system work better. And so it was a natural transition to think about ways that we could bring government data to life with appropriate privacy and security protections.“For the first time, physician leaders who were thinking about their patients, who previously only had a window into their lives based on when they came into the practice, could now more fully understand what happened before the patient came in or after they left.”Mr. Gomes:Tell us about your startup, NavHealth, and its parent company, Hunch Analytics. For example, you work at Jefferson Health and DVACO, the Delaware Valley ACO. How might this collaboration serve as an example of how asking the right questions, finding the right data, and applying the right technologies to solve dilemmas can bring about fundamental change?Mr. Chopra:I cofounded Hunch Analytics with Dan Ross and Sanju Bansal, a successful entrepreneur who cofounded MicroStrategy, a business intelligence software company. Sanju set aside some research and development money to prototype products built on open data sets held by the government that could be brought to life specifically in health and education markets.Top on that list was the Medicare ACO program. For the first time in history, the federal government is collaborating with organizations like the Delaware Valley ACO and Jefferson within that group, as well as literally 400-plus organizations around the country under contract to release access to the full patient healthcare experience with permission. For the first time, physician leaders who were thinking about their patients, who previously only had a window into their lives based on when they came into the practice, could now more fully understand what happened before the patient came in or after they left. Through the Medicare ACO program, we are able to stitch together these data sets.Mining these data sets is important because I think we are in the most entrepreneurial period in healthcare. Among the areas of greatest innovation is the new set of questions that doctors, nurses, frontline staff and management can start to ask to figure out whether or not segments of patients are currently getting the coordinated care they deserve, or if there are areas in which we might identify better pathways for their care. Then eventually, we can put in place the workflows and applications to make sure that patients and providers navigate these networks to get the right care at the right setting at the right time.So I am proud to be a partner with Jefferson in exploring this information and identifying those patient segments where we can deploy the value-based care delivery system the country so desperately needs.“Mining these data sets is important because I think we are in the most entrepreneurial period in healthcare.”Dr. Klasko:One of the things that I noticed when you were working with President Obama was that the traditional way of looking at government best practices was very similar to how we once looked at healthcare best practices. But you didn't accept that lower standard of best practice just because it was government. We have that issue with medical errors. I often laugh, when a physician leader compromises on his or her goals by saying, “We should be more like a hospital that has cut their infection rates by 10 percent.” That's the wrong standard. Maybe we should go look at another industry that has gotten to zero defects.And I think as I look at one thing that was unique about the way you handled things, you compared government to and brought in best practices from some other nonobvious services and industries that saw similar problems, and what you might be able to learn from those. And then you leveraged those parallels as you began to transform government services.Who do you think we can learn from in healthcare? Where would you say, Steve, forget your traditional standards, this is where you could go to learn and pick up some disruptive quality control, customer service, or technology advice that does not exist in healthcare?Mr. Chopra:It is about context. In the late 1990s, my colleagues at the Advisory Board wrote a book called Stall Points. How do seemingly indestructible companies hit a proverbial brick wall and effectively struggle? And the classic case example is Kodak, which really was the bellwether of the ball, right? They were the most innovative and entrepreneurial company, 90-plus percent market share, and here we are decades later watching their demise.And it turns out that there are some fundamental lessons that can be learned, but among them was their failure to manage their innovation pipeline. To give you an example, they invented the VCR, but management said, “Who is going to spend 500 bucks to buy this device?” and they chose not to commercialize it. They invented digital photography but, again, chose not to commercialize for fear it would compete with their core business on film.The lessons that I drew for the president were really the lessons about how we close this innovation gap, and what are the capabilities that we would need to better manage the innovation pipeline? And so there were three case studies, if you will indulge for a moment, I will share them.The first of those case studies was actually Procter & Gamble, whose CEO, A.G. Lafley, had made a bold proclamation that 50% of all new products sold by Procter & Gamble would come from ideas that originated outside of their famous lab network. I called their CTO and, jokingly, said, “Oh, my goodness, your boss just punched you in the gut. You are only good for half the productivity. Is that embarrassing?” And he said, “Quite the opposite. I mean, he gave me air cover to do what I always naturally wanted to do, which is to reach out.”You know, we believe in Joy's Law. Joy's Law is attributed to the founder of Sun Microsystems, Bill Joy, who said, “No matter who you are, the smartest people working on the issues you care about work for someone else.” That idea of open innovation, opening up the doors, the cultural commitment to find those ideas and welcome them, not kill them at the edge, was an important attribute that we learned from Procter & Gamble.Although somewhat controversial today, Jeff Bezos at Amazon actually created a model where frontline workers could be rewarded for new ideas that they experimented with, even if those new ideas were not really reported up through management or approved. He rewarded people with these old Nike sneakers to say, “Thank you for trying.” You know, the Just Do It awards. And it sent the message that basically there is innovation that can take place from the bottom-up. Imagine 3 million frontline workers actively contributing ideas for the president's key priorities?And then lastly, and the one most relevant, I think, for where we are going in healthcare, is actually Facebook, but in the context of their developer platform. At the time, Facebook had something like 3,000 employees. But if you searched how many people had the job title Facebook developer, there were over 30,000 people who were contributing to the Facebook platform. And that meant Nike would hire a Facebook developer if they wanted to build that experience.I would look at those three threads, Steve. What is the right cultural statement to surface ideas from the outside in? How do we value frontline workers up and down, bottom-up, not top-down? And then how do we build platforms so that people all across the enterprise, in and out, can contribute to this pace of change? Those were the big lessons and case studies that we adopted, as we worked to advance the president's open innovation agenda.And then the theme of all this, given your point about the Six Sigma experience, was to adopt a lean startup culture that took all of these ideas and said, “Operationalize them.” We would take the best of lean management principles and the spirit of startups and think about hypothesis generation, prototyping, feedback, adjusting on the fly and thinking of cycle times measured in weeks and months, not years, or election cycles.“The lessons that I drew for the president were really the lessons about how we close this innovation gap, and what are the capabilities that we would need to better manage the innovation pipeline?”Six Sigma ExperienceDr. Klasko:Now that is like a crash course for CMOs, as far as what they probably need to do moving forward. Aneesh, a good part of my research has been on what makes physicians and healthcare leaders different than other people, as to how we handle change.And what we found is that we are sort of in a bad positive feedback cycle, that a major contributor to the inertia in healthcare is a sense of powerlessness. You know, I have the opportunity to visit with medical staff around the country, and it is like the Woody Allen quote, you know, “We are at a crossroads. One road leads to total destruction, the other utter despair. Let us hope we choose the right one.”And then the other problem seems to be even for the physicians that don't feel powerless, they are still blaming everybody else. By the time you get to looking in the mirror, often, it is too late. Given that we both come from very different worlds, how do we overcome this sense of powerlessness? Because there are some realities—decreased NIH funding, decreased inpatient reimbursement, some regulation issues. Suppose President Obama got all the stakeholders together and said, “I want to give you one last shot at getting this together.” And let us just say everybody had to look in the mirror and not blame the person across from them—what would you suggest that a CEO or CMO of a health system or a practicing physician or nurse or senior executive or an executive of a pharmaceutical company or medical device company do immediately?“My hope is that readers of this article might have the following conclusion: That if we collectively punch a hole in that wall of disbelief, we will collectively find out that it is paper-thin, because it is paper-thin.”Mr. Chopra:Well, thank you for the question. This is actually the most exciting question to answer, where we are right now. Let me begin with an observation. My humble opinion is that what you are describing is a wall of disbelief. And my hope is that readers of this article might have the following conclusion: That if we collectively punch a hole in that wall of disbelief, we will collectively find out that it is paper-thin, because it is paper-thin. And I mention this because a lot of the anxiety is misplaced as the facts are the inverse of what people believe.Let us take an example. One of the fears of regulation is the sense that basically Washington is dictating how we get paid, they are telling us what we are supposed to be doing, we do not think they are doing it right, but we can only argue it so much. And there is this sense that you are powerless in the face of this onslaught. Let us just take payments.One of the first myths I would like to myth-bust is in the Affordable Care Act. One of the most powerful provisions of the law is that if you are the CEO of a health system, you have the opportunity to petition and design your own payment bundle. If you believe that you can do something better than anybody else, perhaps for a given patient population with a set of conditions or under definable circumstances, and you want to take risk and responsibility for a specific number of months of their care, you have the opportunity to petition the Medicare Innovation Center to run that as a proverbial payment trial; if that trial works and the independent actuary of the United States asserts that your trial generated value, then that can become a national payment option without having to go back to Congress.Let us take a second example around designing the insurance marketplace. Again, getting everybody around the room and saying, “Is this how we would like to develop the access programs? Is this how you want everybody to get insurance? Is this what a minimum benefit plan should look like? Is this how we should get employers involved?” We could rewrite the healthcare exchange provisions provided we reach the same coverage, cost, and quality assumptions.Another myth to bust—every single state in the country by the year 2017 has the legal authority to rewrite all the major marketplace provisions of the law. If you can come up with a better, more effective way of onboarding Americans into the system to lower costs and to improve outcomes, you can petition the government under the state innovation waiver starting in 2017 and actually get the authority to rewrite major provisions of the Affordable Care Act in your state.And the last, but not least, again, in the spirit of myth-busting, we have this historical perspective about silos. “Well, there is the insurance company, and there is the hospital, and here is the physician, and here is the nursing home, and each of these are separately regulated and governed.” And all of that is true—those are today's silos.But at last, because of some of the technology provisions in the law, we are creating the conditions where organizations that are opening up this data can now collaborate even with organizations that are not owned in a vertical sense, but can create virtual companies that effectively operate together as one to share information, to engage patients, to reward or influence providers, and that we can essentially rebuild the underlying operating infrastructure, the operating system of the healthcare industry.I conclude by saying healthcare is not an area for negativity. In fact, this is the most entrepreneurial period in healthcare's history, with a combination of the amount of data the government is making available about healthcare, the opening up of the health IT systems through these connected applications, and the ability to shift and influence payment models at your pace, which allows people to take the bull by the horns and own this moment. I cannot imagine a more exciting time to be in healthcare than right now.Dr. Klasko:You just tweaked me about something. One of my complaints is that when you really look at what has been done by the private sector in response to the Affordable Care Act, and you look at some of the people that have taken advantage of some of the opportunities you just mentioned, it is a very exciting story—insurers and providers with creative partnerships, industry and academics working together, and even individual entrepreneurs and physician groups moving from volume to value, much of which was spurred by the changes you mentioned. But for whatever reason, it seems like we have let the—to use a bad word—the naysayers take the communication platform. You know, it does not seem like there are a lot of folks going around saying, “Let me tell you that in Pennsylvania or Ohio or Colorado, the CEO of this 300-bed hospital took advantage of their ability to make their own bundled payment system, and this is what they did. That exciting message never materialized.“I cannot imagine a more exciting time to be in healthcare than right now.”Mr. Chopra:I would say to you, there were many factions supporting the president that had different voices. A few of us represented that excitement and enthusiasm. Yes, I personally believe you are in a very important place.And frankly, your Journal, to be blunt about it, could play an important role in helping to surface stories of people who have leveraged the tools that are in the law that may not be as widely understood to really bring about some incredible changes.Mr. Gomes:This is a perfect segue into the next question that I have, and that is, you have dedicated a good portion of your career to understanding the role of interoperability and data sharing in healthcare, and even in education. If you could tell us what drives you to that end. We know you are passionate about these kinds of goals, but what are your core beliefs behind that drive?Mr. Chopra:Yes. Thank you, Neil. If you believe in the value of open innovation, that people will be collaborating to help students succeed or to help building owners reduce their energy consumption, or to help patients achieve greater value for their dollars spent in getting the healthcare outcome they deserve, in each of these stories you will find there are entities collaborating at the edge.And in today's Internet-based economy, much of this requires us to connect often sensitive data. And so one of the market failures we have tried to overcome in the public policy domain are, how might we allow institutions to connect information, especially regulated data, that has historically eluded us for lots of reasons? And the spirit of this is not new. I took inspiration from, believe it or not, President Herbert Hoover when he was secretary of commerce in the late 1920s, just after World War I.What Secretary Hoover had considered was a new role for government. He called it the associative state. That is to say, there were many who wanted him to have the government invest directly in industries that needed a propping-up. His bias was that government really should not be picking winners and losers, but did not want to sit back and let industries fail. His response was, the government could play a convening role to lower barriers to entry and to foster more collaboration on the research and development front, as he had done with aircraft manufacturing with the predecessor to NASA, focused on building airfoils and engine cowlings.To answer your question about interoperability of health and education and energy, we wanted to achieve the spirit of an associative state role, where we can collectively agree that even though each individual organization has access to its own version of a patient's health data, we should standardize the patient summary file format wherever a patient chooses to direct that it be sent.If you are a utility, here is the metering data, and here is how it is shared with your home appliances that want to connect, if the consumer wants it, and so forth. And that has become an incredible role, a bipartisan role of government. The federal government right and left has been asked to carry that spirit along to foster interoperability standards on cybersecurity, on energy, on health and education, and the like.Mr. Gomes:If you were looking at it from a patient perspective, if you wanted to do one major thing that could change that, what do you think of the National Patient Identifier? Would we solve a lot of the interoperability issues if we started this as a foundation for interoperability and data sharing?“How might we allow institutions to connect information, especially regulated data, that has historically eluded us for lots of reasons?”Mr. Chopra:I believe the answer is to empower the patient with full access to their records and their data. The National Patient Identifier would be an option if behind the scenes we wanted to connect all the organizations around the patient's information, which has a lot of security and privacy challenges, and it is a costly proposition to do this behind the scenes.My general opinion, if I had one sort of magic wand, would be that every node in the healthcare delivery system points the data back to the patient or,