111: When Your Government Runs on Windows 95

Quinn:

Welcome to Important, Not Important. My name is Quinn Emmett.

Brian:

And my name is Brian Colbert Kennedy.

Quinn:

And this is science for people who give a shit.

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It's wild that they keep talking to us, these people.

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I'll never get it.

Quinn:

Nope. Those people are scientists, doctors, journalists, engineers, professors, policymakers, educators, CEOs, the whole shebang, even [inaudible 00:00:45].

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Quinn:

That's right. This week, getting a little nerdy, Brian. I'm pretty excited about that. It's something you either don't think about in your everyday life or you think about all of the time for a variety of reasons. We are talking about the past, the present, and the future of government IT infrastructure. Brian, don't laugh. It could save your life one day, my friend.

Brian:

Of course, I am sorry for laughing.

Quinn:

If it hasn't already. Tell them about our guest.

Brian:

Well, our guest is Aneesh Chopra. And he's the first and former CTO of the United States.

Quinn:

A little company you might have heard of.

Brian:

You may have heard of it, and has a better perspective on this than probably anybody on our planet.

Quinn:

That's right. That's right. He's done enormous work inside the machine, outside the machine, partnering with the machine, partnering outside of the machine for so long, and helps us really understand how these things work, what has gone down when they haven't worked, and why? And where we're headed, which is some pretty exciting places. So, many thanks to Aneesh for coming on the show. And yeah, let's go talk to him.

Brian:

Let's listen to him.

Quinn:

Our guest today is Aneesh Chopra. And together, we're digging into questions like, why does the government seemed so compelled to run on Windows 95? And for you young folks, we'll let you know what that means soon enough. Aneesh, welcome.

Aneesh Chopra:

Thank you for having me.

Quinn:

Absolutely, man. Absolutely.

Brian:

Remember Windows 95? That was wild. Aneesh-

Aneesh Chopra:

You joke, but the operating system on my computer when I walked into the White House, really, I couldn't access social... I couldn't access LinkedIn. I couldn't access social media because the browser was so old and unsupportive of any of the modern softwares or service products. So, you joke, but it was actually... that was my life on day one.

Quinn:

I mean, sure. We're going to get into that.

Brian:

Wow, yeah. How is that possible? It needs to be answered. Okay, very exciting. Aneesh-

Quinn:

We're three years into our podcast. Brian just downloaded the Slack app this week.

Brian:

It's so helpful.

Quinn:

Everything's gone-

Brian:

Yeah. It's fantastic.

Quinn:

Yeah.

Brian:

Progress is-

Quinn:

It's so weird.

Brian:

Aneesh, could you tell our listeners who you are and what you do?

Aneesh Chopra:

Sure. So, the name is Aneesh Chopra, and I served as President Obama's Chief Technology Officer. It was a role he created, and I had the honor and privilege of serving as our nation's first. Prior to that, I was Virginia's Secretary of Technology, a relatively new role. I served as the fourth secretary of technology in Governor Kaine's cabinet. And today, I run a company called CareJourney, whose mission is to enable consumers through organizations they trust, to help them better navigate the system to find higher valued care.

Quinn:

It's weird that that has to exist because our system is so cut and dry, and simple.

Aneesh Chopra:

Right, right, right, right, right. We're going to get into all that, I hope. Yes.

Quinn:

Oh, yeah. Absolutely. Absolutely.

Brian:

A quick reminder for everyone, our goal on this show is to provide some context for our question today or our topic at hand. And then, we'll dig into action-oriented questions and what everybody out there can do about what's going on.

Aneesh Chopra:

All right. Let's dive.

Brian:

Let us dive.

Quinn:

Let's do this thing. So, Aneesh, we do like to start with one important question to set the tone for this whole thing. Instead of asking for your entire life story, we'd like to ask, Aneesh, why are you vital to the survival of the species?

Aneesh Chopra:

Well, I think we need to take a great deal of humility on that question.

Quinn:

Sure.

Aneesh Chopra:

I am not. But the role I wish to play is a bit of a translator between the public sector and the private sector. And to me, I believe that remains the most underleveraged interface if you're in the business of solving problems. So, I am of the view that there is a bipartisan, now generational consensus to modernize our society. The premise is that part of the work shall be done by government or the political debate about how much of it should be done by the government. Part of that work shall be done by the private sector.

Aneesh Chopra:

And there will be a political debate about how much. But if we optimize the interface regardless of what percentage of the problem is solved by whichever side, there will always be a handoff. So, optimizing the handshakes and handoffs is about the core mission objective I hope to cover today. And maybe I'll be relevant in some form or fashion to shine light on an area that people don't know much about.

Quinn:

That sounds so logical. That makes so much sense. It's very strange. Well, we appreciate it, because I do think we cover everything from climate to clean energy, to cancer, to healthcare, to-

Brian:

AI.

Quinn:

... Black maternal health outcomes, AI, all of these things. But one of the goals with the show is to really take a deep dive into an issue that is affecting everyone right now. But also, something that despite our community and our listeners being fairly progressive and action-oriented, and nerdy to a respect, there's still some things that are difficult to wrap your head around if you're not in them. And things like public IT infrastructure is one of those that's very, very, very easy to complain about, and understandably so in a lot of ways.

Quinn:

But to fully understand the why of the way it is, is something I want to try to illustrate for folks so that we can get there. Awesome. Well, thank you for being so honest about that, I appreciate it. So, one of the things, again, we want to dive into, is the IT infrastructure, the public and private partnerships, why infrastructure is the way it is, who is behind it? What those partnerships on either side can make us vulnerable to and what it's holding us back from? Does that make sense?

Aneesh Chopra:

Oh, absolutely. I'm happy to dive in right into the deep end of the pool. So, we'll start wherever you want to start out. Maybe I'll just set a couple of facts to set the stage.

Quinn:

Yeah, let's do it.

Aneesh Chopra:

Number one, the US government is probably the single largest customer of IT. Now, it's approaching $100 billion of information technology investments, and probably a quarter of that would be infrastructure. And then, three quarters of the rest of some form of services, applications, and so forth. Now, like any large organization, you often have a bit of historical legacy infrastructure where you've paved the way by being amongst the first to buy computing machines, and then, not the most nimble in upgrading them.

Aneesh Chopra:

You might find a pretty healthy constraint on adapting, purchasing patterns to the new times. So, you might have procurements that still say, "We need Windows 95 for 2020." I'm saying that as a joke, but it may be part of the DNA of our procurement process, just to give you a little bit of a flavor for that, and we probably will go a little bit deeper, it's one of the case studies in failures, but here's an interesting point. The healthcare.gov portal that crashed early in the... obviously, very tragically so in 2013.

Aneesh Chopra:

The procurement on which the contractor was hired to do the job actually was signed in 2007.

Quinn:

Whoa.

Brian:

Geez.

Aneesh Chopra:

Well, no, no, no. Let's just take a second. When did the Affordable Care Act get signed into law? 2010. You might be asking an obvious question, how do you purchase IT for something that did not even exist in law three years early? And you get a little bit of a window as to the challenges we face. Many of our large, disruptive, agile, modern technology investments are enabled by essentially a moat that says, "We're going to limit the number of people who can bid on these future unknown projects.

Aneesh Chopra:

So, we're going to only invite a handful of people who are even available for us to have a conversation about building up what we need. Because otherwise, it'll be too organizationally complicated." So, only a half a dozen companies responded to this general statement. We don't know what we're building or with what intention, what the complexity looks like. We want general technology companies at the ready who can, on the turn of a dime, respond to our requirements so we can get moving.

Aneesh Chopra:

Not an unreasonable concept. But when you fast-forward to the assignment, which is to build the largest shopping portal for healthcare insurance, you would think that the idea someone would have experience building online shopping portals, might have been a top priority. And no, in fact, it was not. And so, you have this challenge where the procurement was 2007. And by the time the requirements came after the law was signed, the agency just turned to whomever was available.

Aneesh Chopra:

And you saw the tragic outcomes, which is they had to listen to every detailed requirement. Maybe they argue, the government didn't spell out every feature and function. And that disconnect leads to a lot of finger pointing, and that's the state of what is essentially a terrible trail of billion-dollar IT failures one after the other, after the other. And it often has its root cause in the failure of procurement, and we'll get into all of this as we dive in.

Quinn:

That's a helpful example. And I feel like, like you said, that's the tip of the iceberg. But it seems to be, for better or worse, the most obvious example for people to grasp onto as we try to illustrate this problem, because it is arguably the most famous and impactful one on the consumer, I feel like at this point.

Aneesh Chopra:

And I do want to tell you, there's a corollary positive story, but I can hold that for later, but I'll defer to you. But-

Quinn:

Yeah. No, for sure.

Aneesh Chopra:

I am not a Debbie Downer. We're going to be talking about lifting up and solving-

Quinn:

Yup. Absolutely.

Aneesh Chopra:

Let's balance the two as we discuss today.

Quinn:

Yeah. Absolutely, absolutely. So, if you could actually take a step back for me, and could you... again, you were the first to do this job for the US. Could you tell us a little bit about how it was advertised to you and what it actually was while you were there, this role of the CTO for the United States, at that point when so much technology was changing and et cetera, et cetera?

Aneesh Chopra:

Well, it's a little bit of a... I'm going to share the immediate answer, but you'll understand that, "Oh, you're not what I thought you were." So, let me do a little bit of a history. Having served as Virginia's Secretary of Technology, think of it as the Minor Leagues to the National Level Major Leagues, okay?

Quinn:

Sure.

Aneesh Chopra:

So, there are only half a dozen states at most that had a role like this. Historically, and I think this is true of corporate America, IT was seen as an overhead function, maybe reporting up through a CFO or a chief operating officer. It's sort of a, "What do you want it to do?" You want the systems to work. You want it to be cost-effective, and you want to have, to some degree, a very clear set of security and liability management processes. It's not a very complicated function. It's basically, "Just do your job.

Aneesh Chopra:

If I call you to get a printer in my office, I don't want a lecture about why I'm moving to digital or we shouldn't be printing paper anymore. Buy me the printer, and leave me alone." Okay?

Quinn:

Sure.

Aneesh Chopra:

So, let's understand that. What the governor of Virginia did, actually a Republican governor. So, this is a bipartisan concept. A Republican governor, a few years earlier than my arrival, had said, "We wanted to build a brand message that Virginia was an internet capital of the world." We happen to have an epicenter for internet traffic. And so, there was a branding around the, start your business in Virginia. We'll plug you into the internet global highway, et cetera.

Aneesh Chopra:

So, we created a secretary of technology position, which aired a bit more on the evangelizing the state to recruit startups and big businesses focused on tech. So, it had almost very little to do with fixing IT procurement, okay? It was largely a marketing function. Governor Warner, who succeeded Governor Gilmore, the Republican, now a Democrat, Governor Warner says, "Ah, I want to fix government procurement." And he decides to shift the focus and make the role a little bit like exclusively focused on modernizing.

Aneesh Chopra:

And he sets apart this 10-year $2 billion procurement to modernize the system in one fell swoop. Big idea, happy to talk about it. Governor Kaine came in with what I refer to a Goldilocks model, and it was what led me to take the US role. Governor Kaine said, "Yeah, I appreciate the marketing role, but you can't give it up, keep going. I appreciate the oversight of our IT infrastructure, keep it going." But my main objective is I want to solve problems.

Aneesh Chopra:

And I care about health, the environment, our educational system, and to some degree, we have the transportation crisis. We have a very acute problem. I want to get people moving in the roads. So, what I want is a technology secretary who will partner and collaborate with my experts in these other domains, so that when they go about policymaking, we are harnessing the full power and potential of the technology data and innovation ecosystem, which may not be their main understanding.

Aneesh Chopra:

But maybe you can be the translator and chief, and collaborator to bring that muscle in. My native culture is collaboration. And so, I love this role. And I basically, proverbially hugged every cabinet member and said, "How can I help?" So, fast-forward to President Obama, he actually forged a relationship with Governor Kaine. There was rumor that he was a finalist to be vice president. So, around that time, the New York Times ran a deep study about, what would Obama administration look like?

Aneesh Chopra:

And the reporter said, "Look to Virginia as an operating model." And Virginia had found a way to go from back of the pack to front of the pack on economic growth per capita. We educated everybody. We had a lot of accolades. And an itty-bitty bullet in there was that we also were best managed state, and best managed state, in large part, was because of our use of information, as it was graded by one of the magazines that scored these things. And so, when President Obama was building up his transition team, they asked if I can serve on it.

Aneesh Chopra:

One of the assignments was to help draft the job description of a future Chief Technology Officer. And it had a lot more to do with that Goldilocks role of bringing these muscles to bear on the bigger problems of our day, less about managing the procurement cycle and the servers, and the cost-effectiveness. We would appoint a CIO. It happened to be my best friend, who was an excellent CIO, who could have that domain. She partnered on everything. As you might imagine, we finished each other's sentences.

Aneesh Chopra:

But there was an inside baseball, outside baseball dimension. And infrastructure is at the center because I couldn't do external collaboration without a well-performing infrastructure. We'll get into some of that. That's how I became in the role, was drafting the job description, waiting for some Silicon Valley luminary to take on the assignment. And lo and behold, the phone call came and said, "I think we decided we're going to go with the Minor Leagues up to the Major. You've been experienced in this place.

Aneesh Chopra:

We don't want to create an unnecessary distraction in the middle of the economic..." as you remember, we're in the middle of an economic crisis, to teach people how to write policy, like the tech, policymaking, just do it at a bigger scale. And that's the assignment I was handed.

Brian:

Incredible.

Quinn:

Fascinating. And we can dig into the details, but I guess briefly, how did that measure up to what you were expecting in the job description that was put together?

Aneesh Chopra:

Well, I'm a nobody, okay? Who am I to ask what the... a White House? Are you kidding me? I'd take this role. And I don't know, I'm thinking I'm going to be sitting in a room and writing words, and crafting memos. Lo and behold, I'm named to the senior staff. You'd call it Assistant to the President and Chief Technology Officer. The Assistant to the President title means that you show up every morning, 8:30 a.m. in the Roosevelt Room of the West Wing.

Aneesh Chopra:

You walk into this building, and you're just pinching yourself like, "Oh, my God, this is the most important place on planet earth." And around the table during a daily huddle, led by the Chief of Staff, then Rahm Emanuel, would be every single person you see on the TV news, right? It's Larry Summers and Tim Geithner. It's Peter Orszag. It's everybody. And who the heck am I? On what planet earth do I need to be in this room, okay?

Aneesh Chopra:

I have nothing to contribute on the big problems of our day, but I listened very carefully to see, "Oh, you're working on this. Let me huddle with you. Let me try this suggestion to this problem." And I really enjoyed the opportunity to react in the moment to the challenges, to bring a little bit of judgment. And then, to hopefully manage some partnership opportunities that could be exemplars to the president that were moving the needle here.

Aneesh Chopra:

And some of them were these colossal failures, like systems breaking, like we couldn't get veterans their GI Bill benefits and sitting homeless, waiting for their stipend to go to graduate school. I mean, it's just frustrating things happened, broken operations. So, we would dive into these periodic problems. But really, it was about the policies around moving up the... opening up the infrastructure, updating and opening up our government infrastructure, which we'll spend more time on.

Aneesh Chopra:

That was the part that was... what I was hoping it would be substantively but just the whole concept of being in this room, at that level, where the president would point out whenever he had cabinet meetings, that these modernization efforts were important to him. That was a fascinating leadership dynamic. You can't force that by law. You can't demand all presidents pay attention to technology.

Aneesh Chopra:

That's something that President Obama was personally passionate about. Not that I was bothering with his time on these issues. This is something he just innately had passion for. And we tried to move the machinery, so that his vision could be brought forward. The notion of a bottom-up change army, we solved problems from outside of Washington, and not inside Washington out. And that culture of bottom-up, it powered the people, if you will, in the digital era, big part of the agenda.

Quinn:

And it seems like I remember the kerfuffle of him get... really refusing to part with his Blackberry when he moved in. Like when we talk about, it's not just the procurement and the infrastructure stuff, it's going like, "Okay, but no. But how do we modernize these things?" And this thing is the very tip of the iceberg going like, "Obviously, it needs to be as secure as it can be," which speaks for a lot of things, but this should be an option. We're clearly moving into a new age.

Aneesh Chopra:

One of my funniest moments in... the West Wing is a skiff. It's a secure facility. So, you can't really bring connected devices per se. And I remember vividly when the iPad first came to market, it was during that first term of the Obama administration. I remember, one of the generals coming in just for one of the meetings in the security room and all that, is with an iPad with him. This is a device that it's connected to all the networks. It could expose things. "Oh, don't you worry. I had DARPA."

Aneesh Chopra:

Which is the R&D arm of the military, all of these features. So, I basically have a brick of an iPad. But I have the iPad, and it's a great vehicle to take notes. So, he was very proud. And then, all of a sudden, I started seeing more of these things popping up. And I'm like, "What is this?" This is the funniest thing ever, but anyway. You're right, there is a symbolic role. The leaders want to use these tools to do their job. And to my point earlier, we literally couldn't touch any social media site from the government.

Aneesh Chopra:

And some of them, obviously frivolous ones, social networks of the personal variety. But frankly, there were many of, how do we get more people to comment on regulations that would impact Black farmers? And why only limited to the PhD lobbyists in DC that only know how to read, the minutiae? Why can't we open up this information, so widely distributed knowledge allows us to get feedback? So, we tried to bring some of these technologies to bear in the running of the government, especially these White House functions like regulatory reform, one of the most boring topics I suppose, for your listeners.

Aneesh Chopra:

But Cass Sunstein, who ran OIRA, the department of the White House that oversaw economically significant regulations, he was a champion of thinking about transparency and public participation in very new ways, leveraging these technologies to get more of the people's voice into the judgments of government. I think that was terrific.

Quinn:

So, I imagine that in a lot of ways, in some ways, a lot of things have changed in those 10 years. But at the same time, I imagine the friction between... and we'll get to the public private part in a second, but the friction between wanting to move forward, but recognizing the things like procurement and legacy code, and code bloat, and things like that, or just policies, were something that held back those efforts to move forward and not just on Blackberries or iPads, or whatever may be, but transparent open-source data and such.

Quinn:

Was that for you an obstacle? And how much do you imagine that is still something people contend with?

Aneesh Chopra:

Look, on the surface, you can give me a hundred reasons why we can't do something. And 95 out of 100 of those maybe, we don't even know what was written 14 years ago when someone wrote the program. There's no documentation, blah, blah, blah. For sure, every meeting began with, "No, and here's why." And I heard that every time I walked into the room. But I believe in MacGyver. And so, when you find the right leader who believes in the vision, you can MacGyver your way through a lot.

Aneesh Chopra:

And just to give you one small example, Dave Kappos, who ran our Patent and Trademark Office, was a committed open government leader, and said, "I want to take this library of patent information, and I want to expose it to the world." Of course, "Oh, it's on vacuum tubes from the '19 whatever, and there's no way to do this, blah, blah, blah." So, Dave had a really clever idea. What if I put out a $0 procurement? No money? You have to figure out a way to extract the data from our vaults in the off hours, 2:00 a.m. to 5:00 a.m. or something, whatever the off hours were.

Aneesh Chopra:

And, oh, by the way, you can't keep this information. For the privilege of doing this annoying work, you have to disclose the results to the public. We got 14 companies competing on a $0 liberate the patent data. And I think Google patents ultimately won, and they put thoughtful engineers on the task of figuring out how to scrape that information with political cover. We were able to liberate that data. Now, if you go to Google patents, you can see everything, right? [crosstalk 00:25:35] got three patents.

Aneesh Chopra:

It's fun to Google his name, and boom, it pops right up. So, that is an example of MacGyver style. But again, those are cute little side car. You got to fix the underlying systems to be better. But a lot of it is culture and believing that you can make progress, and then pushing forward. That's was the 10-year story, is that both Trump administration and Obama administration, and for sure, in the Biden team, there's this commitment to do this as a culture change moving forward.

Quinn:

Yeah. I mean, it seems like we're... look, we're in any situation in any... I mean, I'm a solo entrepreneur in this and a screenwriter. And I'm constantly dealing with... I'm pretty ruthless about the software I use. But at the same time, there's always things that I just don't have time to deal with that I have to rely on that we have to move forward, to say nothing of millions of people employed by federal government or state governments, or even lower local and municipalities.

Quinn:

And I think that became very obvious to folks, obviously, in healthcare.gov, and suffering through that. And then, bringing on this strike team of the US digital service. But that was obviously really evident to people in the past year as local governments and cities, and in some senses, eventually regions or states, tried to build testing portals and also places to sign up for vaccines. And I think it's-

Aneesh Chopra:

Yes. It's all of it.

Quinn:

Yeah. Because I think it's very easy. And again, this is why I really want to paint a picture again, not in a negative way, but in like, this is how the sausage is made way of, why state governments with... not always, but usually, especially something like this with the best intentions, tried to build something that was operable and helpful for people, and city governments tried to build things. And why that is constantly so difficult in a moment? Like now, when all the world is focused on making it work?

Aneesh Chopra:

So, you are onto a very important subject as it relates to infrastructure. And it'll be the transition I think to... I hope a more hopeful side of this, okay?

Quinn:

Yeah, of course.

Aneesh Chopra:

So, nouns versus verbs. There are investments in technology where I need a thing, and it's got to do a job. I need a website for everyone in my state to be able to see all available appointments right now to find the one, and link out the way I do with Kayak, to get a reasonable fare on my plane. Okay. Now, I got to build this thing. The power and the big aha moment for me while I was in government, and I continue to advocate it for it now, is that what we really need is a connection set of verbs. I want information to flow.

Aneesh Chopra:

And while some of this information is held by the government, the vast majority of it is actually held by the private sector. And we have a US policy framework of standards making, standards development, that calls for industry consensus. So, who's got the vaccine in my state? I've got hospitals that are distributing vaccine, and they have electronic health record systems, privately-financed, operated locally. Pharmacies, privately-financed, operated locally, to some degree that public health mass vax systems.

Aneesh Chopra:

So, what if there was a standard that would allow each and every one of those sites to publish their underlying availability data and made it open, so that anyone, a state government, or a .com, could incorporate that to ensure I get access to the information I want? One of the biggest aha moments for me was in the Kaine administration, I got a briefing from a friend of mine, Shailesh Rao, who was working at the time at Google. And he said, "You know, Aneesh, something like 60 %, 70% of the website traffic to a government website on Virginia, your website, actually comes through Google.

Aneesh Chopra:

And oh, by the way, we don't have the ability to access all of your underlying data. So, we don't actually optimize that search experience." If all we did was insert this sitemap protocol for any document you wish to be made publicly available, don't make humans know the URL to go find it. Put the underlying information out, we'll prioritize it in search results because it's a trusted source of information. We'd spent maybe an hour per website to get the webmasters to load the sitemap protocol.

Aneesh Chopra:

Our site traffic went up 40% after we tagged everything. And the reality is, what's the unit of measurement? The unit of measurement is, do I have the information I need to get better care for my loved ones? And so, we're in the middle of recording this episode where proverbially, you wouldn't know the dates and times, but just know that recently, all the major pharmacies with support from the US government had basically quietly developed what's called the Smart Scheduling Links of internet-based API standard for disclosing scheduling slots.

Aneesh Chopra:

And so, we don't have to argue, "Did contractor A, working for state B, do a better job than contractor C in state Z?" What we want to say is... or how many of the source systems have disclosed their slots in an open reusable format so there can be many versions? And that actually is the segue to healthcare.gov. The day healthcare.gov crashed, three or four other private sites, including usnews.com, were live. They were able to go into the underlying databases to say, "What are the available health plans you could buy?"

Aneesh Chopra:

And for lots of technical reasons at the time, you couldn't go all the way to get your tax credits and finish the shopping experience without having the healthcare.gov system actually work. So, that piece didn't quite work out. But as of today, there are dozens, if not hundreds of web brokers, online brokers, health insurance companies, who now have tapped the underlying APIs. So, even if the website, healthcare.gov crashes, you can still calculate tax credits, shop for plans, are growing marketplace of alternatives.

Aneesh Chopra:

And that's the move from nouns to verbs.

Brian:

Wow.

Quinn:

I love that. I mean, APIs are really what hold the internet together and make it as functional as it can be. And I love you used the word, flow, which is like, it shouldn't be this static experience. And it's what enables... I mean, you look at companies like Plaid, the new one that the FinTech company that ties every banking app together, right? And that's the reason you can get your banking data on Mint or any of these other things, or at your bank, or you can send money to this and this.

Aneesh Chopra:

Trick question, what's the role of government in Plaid?

Quinn:

That's a really great question. I don't know the answer.

Brian:

I know, but Aneesh, I'll let you tell.

Aneesh Chopra:

So, in Dodd-Frank, which is the big financial overhaul bill, we included a provision that said, "Functional requirement, the banks, operating checking accounts, must enable consumer application access to their data."

Quinn:

I did not know that was a Dodd-Frank. That's amazing.

Aneesh Chopra:

And here's the best part. Did the Consumer Financial Protection Bureau ever write the regulation explaining in detail how you're supposed to do this?

Quinn:

I assumed, no.

Aneesh Chopra:

No, you're right. And the reason it didn't was the industry self-organized. And solutions like Plaid and its competitors scaled over the last five years. Now, I'm not trying to say the government made Plaid. That's probably a ridiculous overstatement. It created a regulatory foundation of functional requirement on which the private sector built products and services to help accomplish. And as luck would have it, I remember the day I had left the government.

Aneesh Chopra:

But I remember, Jamie Dimon famously cut off mint.com one day and declared that there was a cybersecurity risk. And by the way, he wasn't wrong. Mint was using these screen scraping tools where there was a pre-Plaid, if you will. So, you basically store your username and password, and they couldn't tell the difference between a hacker and a-

Quinn:

And a user.

Aneesh Chopra:

... customer using Mint. So, they cut it off. And I remember Richard Cordray, the regulator said, "Dude, I haven't finalized these regs. You fix this." And within 90 days, Jamie Dimon switched to the OFX API standard, which is the technology stack, that basically is open-source for anyone to reuse. And that now is the bedrock for how you can open up OAuth-based transactions to third parties. So, to me, it's a great example of the role of public-private partnerships, nudging, directing, infrastructure. Is banking infrastructure? Yes.

Aneesh Chopra:

Are we going to argue whether the federal reserve's IT systems are efficient or not?

Quinn:

Sure.

Aneesh Chopra:

Shouldn't I get access to my data that's standardized? And boom, off we go.

Quinn:

So, I'm dying to ask and find out where that layer is for electronic health records 10 years in. But before we get there, I do want to talk about one thing that is in league with this, which is in this public-private partnership, any IT anywhere can be exposed at some level. And there is some news that came out in the election season. So, it hasn't been talked much, about a very large hack around a piece of software called... part of solar wind, essentially.

Quinn:

Where Microsoft was exposed, and it seems like every department of the government. Could you just take a pause and talk us through what happened there, why, and how we can make... again, sometimes you got to go back and clean up the mess before we can keep pushing forward. But how does something like that happen? And why does it happen? Before we get into, "Hey, how do we make APIs for all the electronic health records everywhere?"

Aneesh Chopra:

Yeah. These are exceptional questions. So, let me rewind the tape. Let me do cybersecurity. And then, we'll go into health care.

Quinn:

Yeah.

Aneesh Chopra:

So, one of the most chilling briefings I ever had was from the military that classified cybersecurity as asymmetrical warfare. The idea that you only have to attack with a few 100 lines of code, and the defender has to presume, anticipate every permutation, to protect against the systems. Now, what we decided to do, broadly speaking, was tackle this as a public-private partnership. And it really was the risk framework. Almost everything in life is a risk-reward tradeoff. So, the irony of solar wind is that the very reason it was vulnerable is the very reason we were pushing for cybersecurity.

Aneesh Chopra:

Meaning, you should be monitoring your traffic on your network. In fact, the US government has been updating its traffic monitoring capabilities as well. So, you should be looking for behavior, because assuming there is a hack, you can maybe mitigate the threat by identifying it early. And then, knocking out the port or doing whatever the case may be. So, I don't know much. Obviously, I haven't been reading on the classified side. But I'm going to tell you the layman's view, that one of the issues when you deploy these monitoring technologies, is how do you update the software?

Aneesh Chopra:

One of the big questions would say, "I don't know." Tesla. Okay, I don't own one, but let's assume I dream to have one at some point. So, say you want to get the latest software release from Tesla. Well, you got to know that the code that's being shipped over the air is going to land in Tesla. The device is going to have to know, my car, that it's coming from a trusted source, accept it. And then, run. One of the reasons why we have not opened up our voting machines to these over-the-air software upgrades is because of the very thing that happened in solar wind.

Aneesh Chopra:

If someone compromises along the way, so it's perceived to be trusted and it allows you... and the word hack is a fascinating one. I would imagine from a solar wind perspective, it was walking through the front door. Oh, this is a normal upgrade, and I'm just going to load the software upgrade like I do all the time, and it'll just sit there and be ready for attack, because I mistakenly... and everything comes down to human error, right? Someone left open a port where trusted code could have been manipulated and shipped over as trusted code.

Aneesh Chopra:

So, we have a lot of work to do when it comes to the traffic, how information will flow? Now, what's interesting about this is that that is where... forget APIs, that's just like internal enterprise software risks for cybersecurity. It's an orthogonal link to the medical records conundrum. The medical records conundrum is actually different, and there's a lot of economic interests for whatever reason that are leveraging this security risk, which is a broad risk, independent of whether I open up an API port or not.

Aneesh Chopra:

It's a broad risk, because my whole enterprise infrastructures, any over-the-air upgrade could create a hole, and people could [crosstalk 00:39:49]. So, what happened was we had to make a couple of decisions. We put $35 billion into electronic health records. We said, "We're going to subsidize legacy on-prem software, hopefully, work with the technology companies as we roll the program out over a decade, so that we would transition towards cloud-based, internet-based sharing." That was the dream.

Aneesh Chopra:

Now, at least from my perspective, it was the dream because I knew early, there was a provocative paper written by Ken Mandel and Zak Kohane at Harvard, why don't we have an iPhone app store for healthcare that came out late 2008? I was susceptible to that argument anyway, but it was great to have it written. So, we put $15 million of R&D in [inaudible 00:40:33]. This would have helped to create an internet-based, safe secure standards for shared data. Here's the key.

Aneesh Chopra:

To do data sharing APIs, you got to have two things, an open data model so that the connector on the other end doesn't have to subscribe to your secret rules. That's where you get all the business conflict. And you got to have the query language, so that information can respond to a... you can establish the query and the response in a consistent way, that you could plug into anyone's socket. We have been on a painfully long journey to map the tens of thousands of custom-designed healthcare data models, in every doctor office, at every hospital, led by some proprietary vendor, often the same vendor has multiple data models.

Aneesh Chopra:

So, you've got this pervasive fragmentation. So, the big lift over the last decade was to start small and incrementally add common data model mappings. So, everyone's converting their data. Even before you share it, you got to convert it. And only now, between now and call it December of 2022, there's been this final push from Congress, in the 21st Century Cures Act, that we need to have open APIs so that payers, providers, doctors, patients, everyone can communicate in an open way.

Aneesh Chopra:

So, the key question you asked me about security, yes, there's always enterprise security risk. But as it relates to the specifics of API management, it's frankly more secure than patient portals. When a human is logging into a website, you can't really tell the difference between a hacker or the real me. You try to with, "Oh, tell me your... I'm texting you a number, and-"

Quinn:

Right. Is this a fire hydrant? Yup.

Aneesh Chopra:

They have all these ways. But fundamentally, that remains a race, a competitive race, to break the systems. What APIs do, unlike a website portal, I'm authenticating the endpoint that's taking the data. So, even if it's Aneesh Chopra authorizing the connection from application one to source two, both have to be trusted and registered on the network. So, it's more secure than a human-accessible database. So, doctors are logging in. Patients are logging in. It's more secure for machines to log in to track who they are and what they're doing.

Aneesh Chopra:

Are they within the approved use? So, I think of APIs in healthcare as opening up the data while locking it down. That's my opinion.

Quinn:

I think it makes a lot of sense. So, I mean, I feel like anyone who's been to a doctor's office can understand, at least the very superficial level that... and I remember seeing somewhere that 80% of healthcare records are text-based. And text-based, so much of that was handwriting for so long. How do we do OCR on that? How do we do standardization of the questions and the answers? There's so much legwork that had to be done over the past decade.

Quinn:

So again, this is what we try to illustrate for folks, is when people are like, "Well, why isn't everything electronic health records?" It's like, you're not doing the legwork to understand the immense amount of truly like manual labor that goes into making things standardized before you can even do APIs and things like that.

Aneesh Chopra:

And the thing that you should know back to regulations is now, we're put... because the government fund is almost half of the budget in healthcare, we're using the power of the purse to push the standardization last mile. So, we've got technology vendors responding, and we've got doctors and hospitals reacting. And the payment system is going to reward this proverbial dream that we can organize this information that's fragmented to find an obvious low-hanging fruit.

Aneesh Chopra:

"Aneesh, if you only did this, you'd get healthier and cost the system less money." If everybody got that advice for every step of their journey... and that's why I have a company called CareJourney, I want to provide that benchmark. And people like you actually do these three things well if they live a better life. You're only doing one of those three, do this and this, and this to get there, like these doctors for your condition. Make sure you get these services, basic things.

Aneesh Chopra:

If we just did the recipe for all of us to stay healthy, man, we would save a trillion dollars of healthcare burden. That's the theory. That's the big rock we're all trying to move societally.

Quinn:

I mean, why, besides everything you've illustrated over this conversation, but talk to me about CareJourney. How does that get started? And what are the fundamental in the sense of like, what can you do for me? What are the fundamental problems that CareJourney is working on for individual people but also to the healthcare system in general?

Aneesh Chopra:

Yeah. Finding high valued doctors that are caring for you and the conditions you're in is a base, but let me start with the big picture.

Quinn:

Please.

Aneesh Chopra:

In the Affordable Care Act, we had obviously the big, big, big, publicly-known enchilada to move was, we're going to expand access to the uninsured, namely the young and poor, who don't have employer-based coverage. That was the big news. But there's actually a pretty significant part of the care delivery transformation in the Affordable Care Act. Part of it was, let's tweak the payment system so we're going to reward doctors who deliver better care. That's an incentive, economics play.

Aneesh Chopra:

But the other piece was a data play. We agreed to release Medicare data for the purposes of measuring the performance of the system. That was in law. Think about it. Every single Medicare patient leaves a receipt for every time they go to the doctor, and for what reason? Most of that information is stored mostly for back-end, like back to government infrastructure. Its primary function is to pay doctors for the claim. But the secondary benefit is if you could look at all of that data, you could figure out for a hand problem the best hand surgeon in Chicago is X, Y and Z.

Aneesh Chopra:

Now, the best, you and I know of how to find the best hand surgeon is, we may have a friend who's got a friend, who's got a friend that knows doctors. And so, that's the-

Quinn:

I mean, that's 99% of the time, right?

Aneesh Chopra:

It is, or you go to like Yelp reviews, and you think about spamming, "Oh, this doctor is horrible. This person is great." Where's the objective data-driven information to say, "This person did 75 hand surgeries last year on people like you. And their outcomes were this relative to the neighbors down the street. You can choose to do this, that, or the other"? We don't know the price. The societies got all these secret society prices. Walls are coming down there too.

Aneesh Chopra:

But at a minimum on basic questions of who treats people like me and how well do they treat people like me relative to the others, the answers to this question are in an open government database. CareJourney applied for a research license, to be able to tap that very sensitive data. We're one of half a dozen companies that are privately-financed to do this. And our business model is to conduct these objective reviews using open algorithms to measure value and to compare doctors in a five-star rating engine.

Aneesh Chopra:

And then, we disseminate those findings to members who chip in an annual fee to get access and use it. So, some use it to educate their primary care doctors, who should they refer to? Others use it to say, "I'm going to take risk in a given market. I'm going to pick Dr. Smith to be the anchor of my network." And I'm hoping, we haven't gotten there yet, people are going to build next generation FindADoc websites, where they'll be powered by a value-based ratings engine, instead of sort by last name and sort by specialty.

Aneesh Chopra:

It can be sorted by value. And we would love to be that open scoring system, akin to FICO scores, on high value healthcare. That's really the dream, and we're growing. We got 90 some odd numbers. We got 75 people. We've had a great year despite the tragedy of the pandemic. So, we're really doubling down on the vision.

Quinn:

I love it. And there's so much, for lack of a better word, unsexy work to be done that can save lives, improve lives, but also make the system on a hyperlocal level. But also, a national level for things like Medicare or Medicaid, so much cheaper, and have so much more value, and be so much more affordable for everyone. And last night when I was looking through CareJourney, I read through the stuff on the ET3 model.

Aneesh Chopra:

Oh, yes.

Quinn:

So, I have a particular affiliation for this. One of my very good friends works for a research hospital in Southwest Virginia. And his entire job is figuring out how to make people come to the emergency room less and how to make people... they're literally about to start a trial where ambulances take people somewhere else other than the emergency room, which is a primary care doctor or an urgent care-

Aneesh Chopra:

Public-private partnership.

Quinn:

Exactly.

Aneesh Chopra:

Oh, is that valid health? I don't know if you want to name it. But that's-

Quinn:

I'll leave it out for now, but it's not.

Aneesh Chopra:

Yeah. Or there's only a few options. So, [crosstalk 00:49:55], whatever. But who knows who it is? Let's just stay whomever it is. The theory is, that is a public-private partnership. I call 911, I'm calling the government. Who can help predict the nature of my condition and the best intervention for me? And so, there is a role of government. There's a role of data and innovation, so that the health system in question is thinking about this. Anyway, so you get the idea. And think about what this means for American competitiveness.

Aneesh Chopra:

With our GDP increasingly consumed by healthcare data, healthcare costs, we are unable to compete with China for the jobs and industries of the future. And each dollar we're in excess that we pay in healthcare for weaker outcomes, is a tax on our innovation capacity. So, the more we can wrangle out the inefficiencies, and we've got to do it in a uniquely American public-private partnership way. We don't want to have a big battle over putting doctors on salary and cutting their revenue by half.

Aneesh Chopra:

We could do those draconian things if we had to make the budget work, but we've got to innovate our ways through it, especially when we know it's feasible. Avoiding those unnecessary ambulance visits for something that can be treated at an urgent care or at home, or with your primary care doc, what a savings. It's three quarters of a billion dollars in Medicare alone.

Quinn:

For everyone. I mean, everyone is terrified when they get that emergency room bill. You feel good when you're in the hands and they're paying attention to you, until you get the bill later. When like you said, so much of that can be done in urgent care, even a primary care doctor. I mean, it's just a massive difference. And as long as we're still saving the same amount of lives and people are feeling better, and we're saving money, I mean it could be a game changer. So, on that note, what is next?

Quinn:

Yeah, I know you got to roll. So, if you have two or three minutes, whatever you have, tell me, what is next for you guys? Actually, in the sense of they wrote this week, one of our heroes in climate change, Dr. Leah Stokes, was giving a talk on TV and said, "Look, good politics is passing policies that actually affect people's lives." What is that for healthcare in these public-private partnerships? What's coming?

Aneesh Chopra:

To me, I think there'll be a whole new business line called a health information fiduciary that layers around the system as complex as it is today. And its business model will be that you authorize it with access to the information that you can aggregate. You will get guidance on what decisions to make. And any of the efficiencies gained from what would have happened if you were in the traditional fragmented system towards this better system where you're running more effectively, you're rewarded for that arbitrage.

Aneesh Chopra:

That is the business model known as value-based care. And particularly, consumer-designated value-based care networks. That is the health information fiduciary. That is the entity that I believe a doctor network could stand up, a health plan could stand up, Walmart, Walgreens could stand up. There are many places that wish to serve and compete on trust to help you make relatively straightforward decisions, that actually is in your best interest, not the sponsor of the ad on TV to buy drug acts that may not actually be in your best interest relative to the alternative.

Aneesh Chopra:

So, that's the muscle we need in the healthcare economy, and all we at CareJourney want to do is to fuel those fiduciaries with the decision support and benchmarks they need to be more successful at what they do. So, we'd like to be the Intel Inside for health information fiduciaries. That's the basic principle.

Quinn:

That's a pretty great '90s reference, the Intel Inside. Yeah, the sticker was on everything. Well, listen, we know you got to roll. We really appreciate you taking us through this today. I feel like you and the folks who've been working on this for so long, have put in so much time and bandwidth over the past 10 years to get us to a place where we can start to unlock some of these incredible things. And people will be able to hopefully soon really appreciate what that work has meant because they will see that value in their life.

Aneesh Chopra:

Amen.

Quinn:

Well, listen, thank you so much.

Aneesh Chopra:

Thank you, guys. [crosstalk 00:54:19] incredible.

Quinn:

We really appreciate the time. And-

Aneesh Chopra:

Have a great day, guys. I'm late.

Quinn:

Keep it up.

Aneesh Chopra:

Thank you guys so much.

Brian:

Thank you.

Quinn:

Get out of here. Please, of course.

Aneesh Chopra:

Have a great one. Take care.

Quinn:

Thank you so much. Take care.

Aneesh Chopra:

Bye, bye.

Quinn:

Thanks to our incredible guest today, and thanks to all of you for tuning in. We hope this episode has made your commute or awesome workout, or dishwashing, or fucking dog walking late at night, that much more pleasant. As a reminder, please subscribe to our free email newsletter at importantnotimportant.com. It is all the news most vital to our survival as a species.

Brian:

And you can follow us all over the internet. You can find us on Twitter @importantnotimp. It's just so weird. Also on Facebook and Instagram, @importantnotimportant. Pinterest and Tumblr, the same thing. So, check us out. Follow us. Share us. Like us. You know the deal. And please, subscribe to our show wherever you listen to things like this. And if you're really fucking awesome, rate us on Apple Podcast. Keep the lights on. Thanks.

Quinn:

Please.

Brian:

And you can find the show notes from today right in your little podcast player and at our website, importantnotimportant.com.

Quinn:

Thanks to the very awesome, Tim Blane, for our jam and music, to all of you for listening. And finally, most importantly, to our moms for making us. Have a great day.

Brian:

Thanks, guys.