HIMSS 2019: Best Time in History to Develop Consumer Applications for Health with Aneesh Chopra

This Week in Health IT Aneesh Chopra
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Democrats and Republicans from three administrations spanning decades delivered a HIMSS keynote discussion where they declared bipartisan agreement on consumer centric interoperability. Aneesh Chopra helps us explore what this means for Health IT.

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Bill Russell:                   00:11                Welcome to this week in health it where we discuss the news information and emerging thought with leaders from across the health care industry. This is Bill Russell. Recovering healthcare CIO and creator of this week in health it, a set of podcasts and videos dedicated to training the next generation of health it leaders. This podcast is brought to you by health lyrics, helping you build agile, efficient and effective health it let’s talk visit health to schedule your free consultation. We were recording a series of discussions with industry influencers at the Chime Himsss 2019 conference. Here’s another of these great conversations. Hope you enjoy.

Bill Russell:                   00:46                Here we are again from the hymns for we have a Aneesh Chopra here. Nice. Always a pleasure.

Aneesh Chopra:            00:50                Bill. Thank you.

Bill Russell:                   00:51                I see you’re partaking from the various booths that are out here.

Aneesh Chopra:            00:55                That’s right, it’s the benefit of Himss

Bill Russell:                   00:55                It is an amazing, so, uh, hey, great keynote. That was a, that was phenomenal. Um, three administrations. Yeah, Democrat, Republican, um, multiple decades. It’s unbelievable how long and we’ve been talking about this for a while. So a lot of big things happening in interoperability. Why don’t you give us a rundown of just some of the things you guys talked about on uh, on the keynote and go from there?

Aneesh Chopra:            01:19                There were really three things that cap and then I think you’re going to make, I don’t want to see that this is the year that we see material progress cause it may feel a little bit like, well everyone says that. I genuinely believe it. Three things we spoke of. One, the new default in interoperability is that the patient and the apps that they choose will be the destination for health information. So format. patient centric interoperability. That’s right. That was the default. And that came through not just in spiritual language to aspirationally, we should do this. It even came out of economics. The rules now say any consumer APP, uh, with the uh, consumers opt in, we’ll have free access to the data. No fees, no burden, no special effort. So that was point number one, consumer at the center. Point number two, and this is interesting, the decades even we’ve been at this have been about EHR doctors, hospitals, we now introduced regulation on the health plans. That’s a pretty bold statement. And now we’re going to have standardized claims data to combine with standardized clinical data. And I think it creates the momentum that basically says we’re going to be unfettered and moving all of healthcare data towards a common language that’s available to consumers via open API APIs. And that will cover social determinants of health. It’ll cover prescription data, pricing, data quality, got a whole range of topics. That’s 0.2. And then last but not least, and this is the interesting one, and I’m going to float this idea with you, bill, and you’re going to react one way or the other. And they were entering into a net neutrality era for healthcare data and business models. And so what that means is that the rules, information blocking rules allow, that if you’re data and you have to invest in API technology in order to release the data, you can recoup those costs by charging fees to the applications that wish to connect, not the consumer’s fees, uh, apps, but the, uh, physicians apps and other apps. But those fees have to be tied to the marginal cost of the program. And that also means that you are allowed to provide value added services, but they have to be nondiscriminatory and they are likely to be competitive. So you can’t have the fact that you’re in possession of the data to be the sole source of said value added service and prediction model, a service here, there and the other. But rather others should be able to compete to deliver that last mile, the doctors, the insurance companies, to anybody else. That’s a powerful concept because it puts in place a nice rule of the road for what’s been a gray area about economics as he moved to an API based, uh, uh, interoperability market calls.

Bill Russell:                   03:54                All right, so I’m going to some of what you say is policy speak. Yes, it is. So the first two is very easy the third, the third one, complicated. All right. So again, we’re going to be talking to the it organizations predominantly on this podcast So let’s assume I have an innovation arm. We’re going to develop an application. The application is, uh, I’m gonna use Blue Button 2.0 I’m going to get that data.

Bill Russell:                   04:13                I’m going to get the data from the health plan, the data from the health system. That’s right. And I am now going to have a consumer based application that they put all that data in there and it’s going to identify where they can go for durable goods where they can go for us. You know, it’s almost like a, uh, like an Uber for care navigation. That’s right. All right. So we just dropped that up.

Aneesh Chopra:            04:32                They get the easy pass where they can connect to all those source systems at no marginal cost.

Bill Russell:                   04:36                Right? But who, who do I have to pay? So one of the

Aneesh Chopra:            04:40                nobody, nobody on the consume sider.

Bill Russell:                   04:42                So you talked about an incremental cost and an incremental value and on the, I heard cost.

Aneesh Chopra:            04:47                Yeah. So here we go. So if you’re the supplier of the data, if you’re the health system and you’ve just made this investment to upgrade to stage three meaningful use, what we used to call meaningful use promoting inoperability. And you have this Api gateway where consumers can connect apps. You’ve got to find a way to incorporate that cost into your delivery model. However, if an application developer wants to connect to an insurance company wants to grab information on behalf of the whole population or maybe a value added service that wants to sell into the organization that wants to maybe offer a prediction model or some other value added service. Those applications may pay either the hospital or the EHR vendor a reasonable fee to access the data to perform their service. That is what’s regulated. I call that net neutrality because there is a cost of running multiple applications in the enterprise and if it’s tapping into the database that’s been built, uh, for meaningful use or for the consumer use case, that extra cost of managing it will have to be recouped somewhere.

Bill Russell:                   05:54                No one’s going to just say this is all an unfettered access. Now the question is, can I charge one price for bill cause you’re my buddy and another price to Suzy who’s a competitor and may do things that I don’t really believe should be done or is it going to undercut need for my service? I cannot discriminate on the fees that we’ve charged to recoup the costs and nor can I discriminate on what the value added services have to be able to compete in an open marketplace.

Bill Russell:                   06:22                So even if I’m not in the innovation arm of said health system, correct. I can just develop with you and I could go off, come off this app and then go, hey, we’re tapping into your data. That’s right. And the beauty of it is there’s no baas, no business associate agreements, no data use agreements because it’s going to the individual, the consumer has the right to pull the data out of a HIPAA covered entity or a hospital or doctor’s office and move it to an application that they trust to use in whatever manner they wish.

Bill Russell:                   06:49                What about between me? So I’m, I’m developing it and the health system, it doesn’t, the health system, nope. They’re not required to make sure that I’m going to protect the data. So I’m responsible for making sure I protect the data.

Aneesh Chopra:            07:00                And in fact you’re onto an important subject, which is how are we going to regulate all of these applications and bills making in a garage or Susie’s making a startup in silicon valley. And the answer is right now they’re unregulated apps, but we are working through the Karan alliance that I have the opportunity service cochair of to work with other stakeholders in the industry on making sure we have a code of conduct so that these applications behave in a certain manner and that they communicate to patients are going to behave in a certain manner and if they didn’t lie or mislead their customer, they’re going to be regulated by the Federal Trade Commission.

Bill Russell:                   07:35                So will there be a certification process for these?

Aneesh Chopra:            07:37                We have to see that happen. We are waiting to see what the right model is. One short term example would be we announced a collaboration with uh, uh, smart or the Ken Mandl andZakho Ohanian a team at Harvard where they already have an app gallery, the smart app gallery. There might be a badge that says I endorsed the code of conduct and that may be a way of communicating that they’re going to honor this. And if they lie, then that can be the basis of,

Bill Russell:                   08:01                so you kept talking about a Roku box? I did. It was that like just a fire servers that essentially what you’re getting,

Aneesh Chopra:            08:06                what I’m describing here is that uh, there will be a set top box at every doctor’s office and every hospital and the person that logs into that set top box is the consumer with an APP in her hands. And so now the question is today, what channels can she subscribed to? And I was jokingly referring to the common clinical data set. I’ve referenced it to be the PBS without Downton Abbey. And the comment there was that it’s okay and it’s useful. But if you’re trying to understand the clinical progression of my cancer, right, you might want to have access to the underlying notes

Bill Russell:                   08:38                a lot more clinical data.

Aneesh Chopra:            08:39                Right? So now the question is how quickly can we add channels to said Roku box. And I believe we will be adding channels. At the pace of industry consensus, they may be outside of the EHR consensus process. It may be the cloud vendors and does things that maybe a specialty areas like imaging and others. But the pace of consensus is what will drive the provision of those, uh, standards based open channels.

Bill Russell:                   09:08                So I want to bring you back, yeah, beacause again, Roku box. So I’m talking to, we’re talking to a lot of people are gonna have to input this. Yes, they say ok, okay. It’s fire server. Yes it is. But uh, when you describe a Roku box or sounds like, oh, it’s apple TV, you just plug it in. All of a sudden it’s pulling the data from all sets and making it available, but they probably have some work to do. It’s not,

Aneesh Chopra:            09:26                well, you’re onto an important subject. And this is where the question between EHR vendors and third party Rokus come into play. That’s why I referred to it. Not as apple TV or Amazon prime, which are tethered to things that are fully integrated packages. But Roku, which is an open platform. The issue for me right now is every hospital that goes live on the 2015 edition of their certified Ehr, they are going to get combined the heavy lifting that their vendor had done to convert whatever the proprietary data model was inside their organization into the fire data model which is open and then through a gateway to connect to apps that register and are securely managed. Now you can have your EHR vendor own that entire stack from the set top box all the way to the converted any of the data to create the channel and a lot of scenarios as well. I think that’s the default, but there should be enough competitive pressure that if that does not behave the way they wish or if they would like to move faster or they would like to have some other role to play, that there may be an opportunity to substitute kind of jail break. Your a Roku so that you can have your own version that sits on top of what all that heavy work was done. So if I’ve converted the data to the fire data model, that’s the heavy lifting that you’re getting from the EHR vendor. Now how you manage access to it. That’s API management.

Bill Russell:                   10:53                Now, am I not going to get ahead of the standard if I do this.

Aneesh Chopra:            10:57                you are onto something really important, here’s the gap today. Right now there is a draft specification. It’s essentially final for a fire based scheduling resource,

Bill Russell:                   11:09                but you’re going to do this in all of these areas.

Aneesh Chopra:            11:10                Well, let’s start with scheduling. It’s live. How many hospitals are introduction on the fire based scheduling module? It’s that was published a year ago. I wouldn’t imagine that. Well now how many hospitals pay a third party vendor x hundred dollars a month to allow online scheduling on top of their systems? Majority. And how many of those Cio’s knew that they could have asked their vendor for the fire scheduling option, potentially lowering the cost of integration. Maybe they did know and they didn’t care. Maybe they didn’t really see the value and they were happy to pay the price.

Bill Russell:                   11:43                So this is the conversation. This, this is great because this was like the conversation we had with her drink. Yes it is. These, these CIO’s are so busy, I come to this conference, they, they hear some, somebody from exponential medicine talk about AI and they’re like, oh crap, there’s something else I have to get in front of it and I got to do fire and I’ve got to do, I’ve got to do all the,

Aneesh Chopra:            12:01                So what if this wasn’t the CIO’s job, alright, well, and we’re seeing that, right?

Bill Russell:                   12:04                We’re seeing the CIO become a CIO, chief digital officer and chief innovation. We’re seeing it break out,

Aneesh Chopra:            12:11                you hit the nail right on the head. I’m the CEO of the health system and I say, okay, I have to negotiate negotiated value based care contract. I got to extend my clinical integrated network. I want to do a better job of engaging my patients. I have all these goals and aspirations for my organization and they’re all on top of technology and they are built on the assumption that I can move the data to where it’s needed to do a job. If I’m told by my it department that you can’t, you have to wait, you’ve got to pay extra, I will fail. Right? And so CEOs are asking the question, am I getting the advice that I need to maximize the value of all this infrastructure? And I would argue there’s more to be done.

Bill Russell:                   12:55                Right. And this is great conversation. So Governor Leavitt, last thing. Yes sir. Call to action. Yes. Uh, and I thought it was a great call to action of all right. Policies in place.

Aneesh Chopra:            13:05                Yes, it is the floor is set. Let’s raise the roof.

Bill Russell:                   13:08                But we’ve set floors before and people didn’t go to that. So what’s it going to take for that call to action to really take root?

Aneesh Chopra:            13:14                Well, to me, I think there’s now a new sense of urgency and new business models, new actors on the stage and new infrastructure. So the marginal cost of adding a channel on the Roku box will be a heck of a lot lower now than if we tried to add the channel, uh, a year or two, three years ago. And that lowering of costs, emergence of new business models, they’re all converging at this time to say let’s move fast.

Aneesh Chopra:            13:38                So you’re saying the field of set ground is fertile

Bill Russell:                   13:40                and with yesterday’s rules are the rules that we announced this week. We have a much clearer perspective about where we’re going. We’re not having a debate about is it this format or that format and that’s great. We’re going cause we work. We used to. So thank you sir. Thank you.

Bill Russell:                   14:01                I hope you enjoyed this conversation. This shows a production of this week in health it for more great content. You can check out our website or the youtube channel at Thanks for listening. That’s all for now.


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