When the pandemic hit, millions of Americans found themselves in a tight spot. While they knew they had to practice social distancing, what were they to do if they had a health condition that requires seeing a doctor?
The U.S. has made huge investments in technology over the past decade to transform the way people access health care. But as health technology expert Aneesh Chopra explains on the latest episode of The Dose, we still haven’t realized the full potential of digitization when it comes to delivering care.
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Illustration by Rose Wong
Bio: Aneesh Chopra
SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. Today’s episode is about how technology influences the way people get health care. We recorded it a few months ago, so you won’t hear us talking about COVID-19, but the pandemic has revealed just how important technology is for health care. When people can’t make it to their doctor’s office, digital care can be lifesaving. Right before we recorded the show, I’d had a terrible personal experience trying to get some routine tests results faxed — faxed, in 2020 — from my primary care doctor’s office to a specialist. And even though my primary care doctor faxed my test results weeks before my appointment, the specialist’s office called me three times to remind me that I needed to do this. When I finally went to see the specialist, even though they had all my faxed records, I had to fill out several forms, once online and then again in person.
And I know I’m not the only person to be frustrated with the way electronic health records work. So I asked Aneesh Chopra to help me understand what went wrong. Aneesh is the president of CareJourney, a company that uses open data to help rate physicians on costs and outcomes. He’s also an expert and has worked in the field of health and technology for many years. And so today we’re going to talk about what technology can do to change the way we get health care and patients access their health data and where technology falls short.
Aneesh, welcome to the show.
ANEESH CHOPRA: Thank you so much, Shanoor. That was just humbling to hear you share that vignette, and yet we see that story play out in every community, in every corner of the country, and you know right here the nature of the problem for how our delivery system is underperforming its capacity and its benchmarks around the world.
SHANOOR SEERVAI: I’m glad you say, Aneesh, that this is a problem across the country and that this is not a narcissistic endeavor where I want you to only help me solve my problems. But really, why did this happen? Why was it so inconvenient to get my results transferred from one health system to another?
ANEESH CHOPRA: It starts with a fundamental premise that our health care delivery system is fragmented and it’s designed to optimize the specific encounter. When you show up to meet with a physician or a clinician of any sort that they’ll diagnose you and resolve whatever challenge you face, whether that be ordering a test for diagnosis or prescribing you a particular medication, it doesn’t really solve for our longer-term connected health experience. So the mere fact that you had a test in one environment, transferring that to the next environment seems obvious. But that’s not the nature of the system that we operate in today. Technology really is about a capacity or capability in service to a customer’s need, and for the last decade, as we’ve invested in the digitization of health care, the customer’s need has largely been to improve the fee-for-service experience, predominantly around billing and administrative burden for that specific encounter.
It’s not been the job of the delivery system to more seamlessly incorporate information about your past and to more easily transfer information about where you’re heading to others outside of their individual system. So this is really an indictment of the business model of health care, more so than the ineptitude of technology as it relates. It is a bipartisan view that if society invested in the digitization of health care, it should result a reduction in duplication, better care coordination, overall improvements in quality. This was sort of a bipartisan hypothesis.
SHANOOR SEERVAI: Okay, and less faxes being sent around?
ANEESH CHOPRA: That’s right. In fact, health care is the only standing industry left that relies on faxes. It’s a shockingly embarrassing statement about the state of technology adoption, and there’s a reason for that, we’ll come back to later. In 2008–2009, there was this bipartisan consensus that if we had an investment in the digitization then perhaps we as a society could benefit over the decade and beyond in terms of improvements in the health care system, hopefully on the cost side, but as well on the quality side. Enter the recession, and there was a political moment in time, and this was not so much bipartisan, as you recall, in the history of the political environment in the United States, President Barack Obama said, “Look, we’re going to put a pretty significant investment, three quarters of a trillion dollars, to jumpstart the economy.” And it was President Obama’s judgment that a portion of that investment, which had to be made immediately, could be focused on long-term investments that would be beneficial for the next decade and beyond.
And so, in that context, we the U.S. government, you said we, we the U.S. government, invested $35-plus billion to help doctors and hospitals adopt and use these technologies that we’ve all agreed on both sides of the aisle would generate benefits to the system.
SHANOOR SEERVAI: Mm-hmm.
ANEESH CHOPRA: But we had this chicken-and-egg problem. We had the aspiration that the technologies would work, and we had the funding to pay now. And we faced the conundrum, well, the technologies aren’t exactly where they need to be, but we have to write the check now for the economic recession, so let’s do the following: Let’s spend the money now and let’s capture the equivalent of an IOU from the industry to improve the products and services over time. And that resulted in the Frankenstein experience that you went through. So the debate we’re having in the country around interoperability is effectively the payback period, if I’m going to be keeping with the analogy of debt and IOUs. It reflects the government’s view that a decade into this investment of $35-plus billion we expected the system to do X. It’s fallen considerably short of X, and now we’re going to have to apply some fairly aggressive medicine to get us back on track.
In theory, the industry could have self-organized and done this thoughtfully over time so it didn’t feel like a big moment. But because we’ve missed the mark, we find ourselves in a scenario where we’re going to see a great deal of change in a relatively short period of time because of the failures of self-organization over the last decade.
SHANOOR SEERVAI: Right. And as this investment was being made, Aneesh, a decade ago, you were the chief technology officer at the White House, correct?
ANEESH CHOPRA: That’s right, yes.
SHANOOR SEERVAI: So I imagine that you probably thought a lot about what an ideal situation would look like.
ANEESH CHOPRA: My dream was that we would have had a learning system to mine the data, figure out the problems, organized around value-based care, and then a demand signal for technology to help effectively and efficiently root out the waste. That did not happen because the pace of value-based care adoption was slower relative to the investments in IT, and that’s the Frankenstein world that you experienced.
SHANOOR SEERVAI: So who or what are going to be the avenues through which this consumer-friendly portal were to exist? And what I’m thinking of, honestly, is my iPhone and wondering if there could be a way that the MyHelp app on my iPhone would be the solution. If I could have all my health records, all my test results in there, would that be the solution?
ANEESH CHOPRA: It would part of the solution.
SHANOOR SEERVAI: But then on the other hand, tell me how it would be part of the solution and tell me where again it falls short?
ANEESH CHOPRA: Yeah. So first principle, you should be able to point your phone, proverbial point your phone, to every single physician or health system or health plan that today is a repository for your health information. You should be able to synchronize a copy of all that information into one place on your phone. Again, Android or iPhone. Let’s stick with platform agnostic. You should have a resource on your phone that is capable of connecting to any doctor, any hospital, any health plan that has access to your information today. Job one, keep a copy on your phone. Then job two, there should be a thriving marketplace of applications that will compete to help you make sense of that information. It’s a “yes, and” not an “either/or.” Simply storing the data on your phone doesn’t automatically remind you that you’re due for your wellness visit or that the doctor that you have as your primary care physician typically needs three months in advance to schedule a wellness visit and we’re at the three-month anniversary so we should call now to get that appointment on the first available date.
Those sorts of applications may be sponsored by Apple, or Google on the Android ecosystem, but more often than not, those may be sponsored applications built by your primary care doctor, built by a health plan you like, built by an integrated delivery system you trust, or a start-up or a new company that we’ve never even heard of. There should be equal opportunity for these companies to compete on helping you make sense of your information while the basic infrastructure works, that you can pull it from all these source systems onto your phone. That orchestration needs the scale of the big tech firms to make sure that there’s enough wires to connect to each of those source systems, but that there should be enough trust and competition that you can choose what organization should have access to that information that will compete on privacy, on the quality of the decision support, and that if you find yourself uncomfortable with the app you’ve chosen, you should be able to substitute it out for someone else with the ease of which you can change your weather apps.
There’s a native iPhone weather app, it’s fine, but I separately downloaded the Weather Channel that accesses the same GPS chips on my phone but gives me a different answer or a better context. I should be able to download the Weather Channel to compete with the native iPhone weather app, and that’s what’s coming to health care.
SHANOOR SEERVAI: Mm-hmm. And so I want to say two things about what you just said, Aneesh, because you use the Weather Channel and I use Dark Sky so it’s great that we’re both able to pick the app that works best for us, the app that we trust, to tell us what the weather’s going to be. Very important where we live, obviously, because the weather conditions can be harsh. But the other thing that I’m thinking of here is what you said about trust. If people are worried about their health data being compromised, it’s too late to be worried about that because that’s already happened.
ANEESH CHOPRA: Yes, the regulations we believe have kept our health information secure are actually quite porous and that there are many ways in which that information is put into the hands of others. Most of the data breaches, when you read in the news that Anthem or whomever had a data breach, when you go down to the root cause, it is often a vendor, a company you and I have never heard of that signed a business associate agreement with said entity that ultimately made the mistake in allowing a hacker into your data. So just off the basic information, we’re not exactly in a Nirvana of protection in a world that we have today.
SHANOOR SEERVAI: Mm-hmm. And what you’re saying, as we enter 2020 and we think about apps that we actually trust with our data, the final question that comes to my mind is: There are other apps, other industries, other platforms that we do trust with extremely sensitive data. I’m thinking about my bank apps on my phone.
ANEESH CHOPRA: That’s right.
SHANOOR SEERVAI: I use Chase and the Bank of America app sometimes to just pay my rent or transfer money. Venmo, which I use all the time to pay my friends when we go out for dinner and we split the bill. So there is a universe in which we trust technology companies’ apps to protect our data that’s sensitive. Are we going to arrive at a point like that when it comes to health data?
ANEESH CHOPRA: Well, you said something very interesting. You put Venmo in the same sentence as Chase.
SHANOOR SEERVAI: I did.
ANEESH CHOPRA: And I’d like to clarify the record. When your data is held by Chase, they are subject to significant privacy laws. The same as you would imagine a HIPAA-covered entity would be in health care.
SHANOOR SEERVAI: Okay, because it’s a big bank.
ANEESH CHOPRA: That’s right, banks are regulated. Is Venmo regulated as a bank?
SHANOOR SEERVAI: I guess not.
ANEESH CHOPRA: No, it’s a consumer-trusted app. You had a problem that you wanted to solve, which is you wanted to pay your friends to split the bill at dinner, it’s annoying to have to manually calculate who owes what, take out cash, go to the ATM, split the dollars, what a hassle.
SHANOOR SEERVAI: Yeah.
ANEESH CHOPRA: Who remembers afterwards that you owe me this? What a pain in the neck. We can all whip out our phones, type in the number, and we’re done. For that convenience, we took our data out of the regulated system into a consumer-controlled app and then authorized that app to reconnect with the regulated banks. So your Chase account fed your friend’s PNC bank account through Venmo.
SHANOOR SEERVAI: Mm-hmm.
ANEESH CHOPRA: That analogy is exactly where we are in health care. We’ll be introducing Venmo-like products and services that will simplify your life. Some will be focused on the long-term health of a patient with chronically ill conditions. Some will focus on really simple things like ban the fax when I want access to my imaging studies or to lower the time I have to fill out forms. Either way, any one of these frustrations, an app developer today can now compete on helping to address those frustrations by virtue of the fact that the forthcoming regulations will demand that all of these systems must talk to the Venmo equivalent that will come up in health care.
And at the time, Venmo was a start-up. Maybe a dozen employees when you began using it. I don’t know. But they’re unregulated in the context of the way you characterized your use. So the same exact legal rights that you can connect Venmo to your checking account have been around since the Dodd-Frank legislation back in 2010–2011.
SHANOOR SEERVAI: Right.
ANEESH CHOPRA: But in the banking industry, they didn’t have the big equivalent of the banking health record. There was no EHR for banks that was saying, “Whoa, this is bad. You can’t do this. How dare you. This is going to ruin your privacy.” There was no such political pushback. The banks agreed and they reached consensus on the technical standards. And, oh, by the way, they’re the same technical standards that we’ve adopted in health care. We’re using OAuth for security and access, we’re enabling codes of conduct to regulate the apps that are enforceable, and the industry is working in the banking sector, the energy sector. Only in the health care sector have we had a decade of frustration and a lack of progress, even though the technology standards have been the same to be used in all three sectors of the economy.
SHANOOR SEERVAI: And we’re hoping to see that change.
ANEESH CHOPRA: I’m expecting it to change.
SHANOOR SEERVAI: Well, I always like to end on an optimistic note, Aneesh, so that is the perfect level of hope to close with. Thank you so much for joining me today.
ANEESH CHOPRA: Well, thank you for having me.