One on One with HxR Conference Featured Speaker: Peter Levin

Matthew Holt sits down with Peter Levin, CEO of Amida Technology Solutions, to discuss APIs and interfaces, data integration, Blue Button, and so much more. He will be one of many featured speakers at this year’s HxRefactored Conference in Boston, MA from April 5-6, 2016. Click here to register

Matthew Holt: This is Matthew Holt, delighted to be on with Peter Levin.  An old colleague from the years of the early part of the Obama administration — actually, I think until the second term, I believe.  Peter, you were the CTO at the VA.  You’ve been at Health 2.0 a number of times talking about, suicide hotlines and data integration, and of course Blue Button, which is as much your baby as anybody else’s.

So, welcome and we are really delighted to have you in your new role as CEO of Amida Technology Solutions at HxR coming up on April the 5th and 6th this month.

Peter Levin: Well, Matthew, thank you so much for including me in this conversation, and obviously for including me in HxR, and it’s always great to talk to you, and I’m looking forward to this conversation, too.

Matthew Holt: Great stuff.  So let’s go back to — I want to say 2010 when you were making projections of like 25,000 people who might download their records in the VA when you have this new fangled Blue Button thing up.  It’s obviously gone a lot further than that.  And then on the other hand, it hasn’t perhaps gone as far as we’d like– interoperability is still a long way away, both in  the private sector and even in the public sector.

So, give me a sense of what the arc has been and how you think we’re doing in terms of freeing the data, which incidentally is the name of the panel you’re going to be on.

Peter Levin: Yeah. So let me start with the Blue Button conversation, and thank you for the shout out there.  I will say today, what I have said to you in Berlin in November of 2013, which is it’s going better than we had possibly imagined, right?  DJ Patil just put up a White House blog, and I don’t have the number in my head, but I want to say five million people have used it and a 150 million people have access to it.  So as you correctly remembered, what I told Secretary Shinseki at the time that we were launching the program around the time of President Obama’s announcement that I thought we would be on solid ground if we said we would get 25,000 people.  As you might recall, the gag is that we’ve got 25,000 people the first month.

So, for me to be talking to you today about the millions of people that have used it and that rely on it, for me, is there is no better validation and there is no better confirmation that we were on to something then, and I think that we still are.  So, specifically, the Blue Button, I am still very much a proponent of that kind of exchange.  Obviously, I am not– and I think most people are not–religious about whether you’re talking specifically about a Blue Button format or a Blue Button program.  Obviously, for me, I still work on that very hard, but there are many, many choices here.  CCDA Exchange through Direct, the Argonaut Project with FHIR-based exchange, and I really think that we still should be focused on a portfolio of options, some of them patient-centered like Blue Button. I still believe that that’s probably our best shot and certainly what I put a lot of time and energy into from an institution to institution perspective, and those institutions can be insurance companies, healthcare providers, even patient advocacy groups, different disease groups or different kinds of caretaker concerns.  You just want the choice, right?  You just want there to be a number of safe, reliable secure choices.

Frankly, from my perspective, I don’t think we’re doing very well.  I am disappointed as an outspoken member of the community, outspoken and proud member of the community, that if you really look at the number of records that have been exchanged and how they’ve been exchanged and with whom they had been exchanged, there is still an enormous reluctance I would say subjectively still on the part of the incumbent EHR vendors, but not just them, some of the data holders as well, to actually do this. Matthew, I don’t know if you saw, I published a piece recently with Joy Hwang in FCW where we were talking a little bit about how people are still sort of standing behind the shill of privacy as if that’s the reason you shouldn’t be exchanging data.  I don’t see it that way and I think that that edifice is about to fall.

Matthew Holt: So, let me give you two little examples.  So yoy know I have been maundering around the healthcare IT blogosphere. One is Tim Histalk who used CareSync to try to get his data out of an academic medical center somewhere in the Midwest or the South where he lives. Basically he was unable to get them, and actually put in a complaint to OCR, the Office of Civil Rights, I think  they closed this complaint without actually doing too much about it. So he is kind of feeling that there was a lot of effort, but it was pretty much the old world.

I will give you another example– you’ve probably seen my little kid.  I had a lot of problems when he was born, initially getting record between different parts of the same  system and moving stuff around within one hospital on Epic.  A little bit later, which I haven’t written up yet, but I should, he got sick — not very, very ill, but he was sick enough that we got a referral to a pediatrics specialist back at the same big hospital.  But in that case, they had outsourced their pediatrics specialty clinic to Stanford, also on the Epic System.  As I stood behind the pediatrician, I could see her use Care Everywhere from Epic and see the set of records in the Stanford records.  But then when I try to get my parent’s access to the set of record for that one visit, Stanford insisted that I drove down to Stanford and sit in the medical records office and sign something in person, so I never bothered to do it.

Now I have heard many other tales like that.  I also am hearing anecdotally that there is a sort of a movement that people are — those big data holders and the EMR vendors are changing.  So before we think about Epic — before we think about Argonaut and FHIR, where do you think the market is in terms of realizing that what’s been going on forever can’t go on forever?

Peter Levin: Honestly, I don’t think that it has evolved very much in the last couple of years, and we can talk about why, if you want to.  I have some frustrations with how things have been led and how things have been implemented.  There is clearly no urgency anymore on anybody’s side of the table, whether it’s the public sector or the private sector or the commercial sector or not for profit and commercial sectors to be specific.

This is the weird thing about this whole topic, right? You don’t know that you need it until you really need it, and then those episodes tend to be very short, right?  So if you’re in the emergency room and you need access to somebody’s med list, you either have it or you don’t; and if you don’t have it and you’re a clinical care provider, you’re just going to make a best guest, you hope that the patient is coherent enough or that they have some mechanism that gets it for you.  Or if you have some kind of acute condition where access to your medical history could lead to a different or better decision, and you don’t have it in that moment — well, I am at least not aware that anybody has actually been sued for the viscosity of that data exchange?  There is no way to at this point retroactively go back and say, “Well, jeepers.  We know for sure that that patient would not have suffered an adverse reaction or perhaps even that patient wouldn’t have died if only we had that data.”  Of course, the people who have that data are not very forthcoming, not very forward-leaning and sharing those kinds of outcomes with us.

So, part of I think what we’re facing here is that people who are health professionals, but not necessarily clinical care providers — I count myself as one of those — are advocating for a safety cause, a safety mission in an overall global outcome’s perspective where many people who are not involved in the healthcare profession or who don’t see patients every single day, they just don’t think about it that much, unless they have an elderly parent or in your case, your kid who’s now better. But imagine a situation where he didn’t get better as fast and you were still trying to get that data. Let’s say you didn’t know you or you didn’t know me.  Who do you call and what do you say when you have that conversation?

So for me, this is a transcendent moral cause.  I have said that many times, and I think that the nascent data does exist, and we see this now certainly on the payers’ side where at Amida, we do now help some of the payers think about this problem in a more careful way than they have in the past than frankly than they needed to in the past.  We can actually now start in a very gentle, very non-confrontational, very scientific and methodical way think about, well, how do we demonstrate that that access is a good thing, how do we demonstrate that continuity of care, care orchestration, care integration is a good thing.

The data is coming, right?  But for whatever reason, in part momentum, in part history, in part selfish commercial interest and all these things get in the way, and then people just lose interest, right?  Your son does get better and my wife does get better and we don’t do what we thought we were going to do, which is turn this into a larger cause.  But happily, there are people like you who don’t let it go and that’s what gives me optimism.

Matthew Holt: Yeah, my son is a little too well at the moment, actually.

So I want to ask you a bit about the technical evolution of what’s going on, and I was kind of joking before we started that there used to be interface engines and there were armies of consultants building interfaces between different parts of the systems within big hospital systems, and then we have companies who have built on that.  Now, you’re saying a group of newcomers who are using somewhat newer technology, and I put Redox and MI7 and some others in that market, who seem to have a somewhat different approach to that data integration.  Is there something different technically going on that I was missing before?  I know that we have FHIR and some emerging standards, but it’s just something that this happened that it’s sort of exposing in terms of a technical change over the last few years or is it just more people.

Peter Levin: The short answer for me, Matthew, is yes.  As you know, prior to my time in public service and then certainly during it, I have been a longstanding proponent of open source.  For your listeners who may or may not know or be familiar with it, fundamentally we’re talking about the difference between me selling you a proprietary solution for which you pay a license fee, sort of like rent on my intellectual property, or an open solution which is that you don’t get to see the data of course that’s somebody else is private information.  But you do get to see the systems, right?  So there is a new kind of business model, not just unique or peculiar to health, you see this actually in a lot of places right now.  Even for example in cybersecurity, which is a place that we work in a lot, where you do not pay a license fee.

So you’re paying companies and we’re not alone, of course.  Happily, we’re not alone!  You pay us a professional services fee to configure, to customize, to install, and in our case, we’re very happy to report that we get money to operate those systems on behalf of customers.

So, if I were to answer your question, the discriminator to me is that in the past, you had a lot of solutions that were very isolated, ferociously competitive and deliberately not sharing.  They deliberately would keep their data within their systems and charge outrageous fees or do other silly, and I would argue in certain cases unethical, things to keep that data from getting into your hands or into your provider’s hands.  Now, part of what has changed, and we certainly have benefited from that change, part of what has changed is people understand, “Well, look, if we’re not really talking about money anymore, because the open source solutions are less expensive, and if we’re not really talking about vendor lock anymore, if I go with a specific EHR vendor and my official care provider has another one, we may or may not be able to exchange data.”

From that a patient’s perspective, that’s outrageous, right?  From a patient’s perspective at the very least is inconvenient in exactly the moment that you’re looking for convenience.

If you have some kind of serious acute condition, the last thing in the world you want to debate with somebody about is whether you have access to your records or not.  You just need the records to go from your PCP to your specialty care provider full stop, right?  So if we have ways of doing that now that are economical that are super secure and that are easy, easy from the provider perspective, but perhaps most importantly easy from the patient’s perspective, then what’s not to like.  We are seeing the first signs of that change.

Matthew Holt: That’s good to hear, although your cautious optimism, I guess, is the watch word. The last technical question here, which is we’ve heard a lot — obviously, the last year-and-a-half about FHIR and the Argonaut Project sort of advance along and very strong probability that’s sort of new and API-based.  We’re hearing more and more about APIs.  We’ve seen Epic in front of Congress talking about their API.  Whether or not you believe that, there seems to be a greater level of openness going on in an incursion to the “fortress” world, the enterprise world.  You’re certainly seeing more discussions like that. Obviously, you’re seeing more people thinking about open source, although again not as many as you might thought would have done, given its success in the VA and some other countries elsewhere. The question is much more do we need to do in terms of building new standards, API, for APIs and interfaces?  How much of this is technical building out problem and how much of this is a marketing and implementation and convincing people problem?

Peter Levin: Well, look, I mean with great respect to the Argonaut project, which I’m a full throated  supporter of — Amida has built a fire stack where we’ve got a commercial version of this that we install for customers.  So clearly, I put my company’s money and my time where my mouth is.  It is not a technical problem, at least not in my opinion.  I say that again, and I can’t emphasize this enough.  I think the FHIR standard is a great idea and we make money off of it.  But we also know, and I think anybody would tell you, I think the leaders of the Argonaut Project would also not disagree that it actually is being an implementation problem.  This is sort of like the ACH number for money transfers or the 10 digit phone numbers.  It’s a modicum of standardization between the various mobile phone carriers, even though for many years it’s less true today, but for many years they had different kinds of modulation scheme.

You, as a customer, you didn’t know whether it was CDMA or LTE or third generation or fourth generation, you just wanted to dial the freaking phone and get a phone call through and it worked, and it worked because there was enough collaboration there with sufficient cooperation between various carriers that they understood that it was not in their interest to trap people in their specific ecosystems in their particular gardens while they’re not. The same thing happens now today in health data interoperability.

So to the extent that FHIR is a rough analogy, I don’t want to stretch the metaphor too far, but to the extent that fire looks like the ten-digit phone number — great.  It’s not the only one, right?  I mean, there is in fact the Blue Button standard.  There is in fact a CCDA.  There are many, many other ways of doing things, and what you’re finding, the second sort of rock that the people don’t want to do this behind.  The first one is always patient privacy which is just not legitimate, right?  It’s not credible and in any way anymore.  The second is, well, we don’t know what standard to use and we have to wait for the industry to tell us what to do, and that’s non-sense as well.  I mean, these were the major, major objections that we’ve dealt with at the time, and this is now going back unbelievably seven, six years ago around the time of the Obama announcement and the Shinseki announcement about Blue Button, where people were climbing up the walls about how can you give patients their information, and “what if they lose their USB stick”, and it’s not even interoperable.

It’s just all kinds of absolutely nonsense stupid  reasons.  I could be using even more explicit language, right?  It was absolutely nonsense, the reasons that they gave us, and I always think that Eric Shinseki had the best answer to this, which is, going back to veterans at that time, these are people who we trusted to carry loaded weapons with live ammunition to defend our freedom, I think we can trust them with their health records, and I think that you don’t need to be a gun-totting soldier to be trusted with your health record.  In fact, we now know that it is your right to have them.  So people who stand in the way of giving them to you are acting illegally, never mind unethically and immorally.

Matthew Holt: I have much opinion about that.  All right.  So last and not the least, can you give us a very quick plug when you come to HxR of the kinds of things on a more technical level you’re going to be talking about.  So in the session, what might they learn about how you’re thinking about this and what you guys do at Amida?

Peter Levin:  So we’re walking the talk very much along the lines of what I was doing before Veterans Affairs when I was deeply in mesh in the cybersecurity space and while I was at VA where we got to talk about patient-centered models of course, of course Blue Button, the OSEHRA Custodian, making sure that not just from a data perspective, but also from a systems perspective that these things were open that we were having sensible, careful conversations about ways to avoid vendor lock and alternative commercial business models.

So what I expected to be talking about in Boston in a couple of months is how we’ve actually made that dream a reality, right?  So we are doing quite well.  We can always do better.  I don’t want to discourage anyone from applying for a job or approaching us from a customer perspective, but what I hope you and your colleagues and the folks that have been either cheering for us in the front row or sending us good vibes and good karma indirectly, I hope that you will be pleased to know that that model works. This mechanism of releasing the source code and the commercial approach of configuration, customization, integration actually works very nicely and we are starting to see the first trickles of data interoperability in the health space and in places where it never existed before.

So we’re just going to keep hammering that anvil.  We’re pretty sure that we’re on to something here.  We’ve doubled for three consecutive years and this year is not looking so bad.

Matthew Holt: That’s great to hear.  So was Peter Levin   Former CTO of the VA and now CEO of Amida Technology Systems. He will be at a HxR in Boston April 5th and 6th.  So yeah, thanks for your time.  Great catching up with you.  looking forward to seeing you in a couple of months.

Peter Levin: My pleasure.  Thank you very much.  Looking forward to seeing you.

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