Governor Phil Bredesen's Address to HIMSS 2007

New Orleans, February 27, 2007

Photo: State of Tennessee

First of all, let me thank you for the chance to be here and to present some thoughts to you. As I looked at the list of keynote speakers - Steve Ballmer and Colin Powell and Mike Leavitt, among others - I was reminded that this is fast company, and I'm genuinely honored to be invited here and sharing this stage with people of such accomplishment.

I'm not an expert on eHealth matters. This room is full of men and women who are experts, who know vastly more about the field than I do, who deal with issues relating to it daily, who are much more conversant with the latest efforts and issues. I want to do two things in my presentation this morning; update you on the Alliance for e-Health, and then challenge you to think differently about how we bring eHealth to life in the broad world of health care.

I believe the reason I was invited to come here is that I co-chair the State Alliance for e-Health with Jim Douglas, the Governor of Vermont. This project has just begun - our first meeting was in January - and has been organized by the NGA - the National Governor's Association - with the help and support of HHS. The NGA is a bi-partisan organization - in this case a Democratic governor co-chairs the Alliance with a Republican one. Its great strength is that when it can achieve a bipartisan consensus of the nation's governors, it has enormous influence in the Congress and can sometimes break the partisan logjams that are so endemic to Washington.

The charge to Governor Douglas and me is to analyze major issues that states should consider as they engage in electronic health information exchange. The Alliance has a lifetime of three years, although Jim and I would not expect to be co-chairs for the duration; our initial term is one year. The Alliance has recruited some highly qualified people as members, and my hope is that we can not only analyze but ultimately produce some model legislation that states could adopt to address the issues we have identified at the state level.

We are starting out with three Taskforces: One for Health Information Protection, one considering aspects of Health Care Practice, and one considering Communication and Data Exchange. We spent a good part of our first meeting listening to presentations from experts and working with our Commission to structure some specific initial charges to the three Taskforces.

The Privacy Taskforce is now charged with looking at the major state health privacy laws with an eye to how they affect the ability to achieve a workable sharing of information. It is then charged with making recommendations as to how to address such issues. It will work with the Health Information Privacy and Security Collaboration that 33 states and Puerto Rico have begun. Every state has laws on the books that never envisioned interoperable health records, and we need to point the way to cleaning up this landscape.

The Practice Taskforce is charged with looking at licensure laws and regulations and how they affect
eHealth, and to bring us an overview of the liability issues that may arise. I would add that these issues are important not only to interoperability, but also to a national response to a pandemic or major disaster.

The Communications and Data Exchange Taskforce is charged with looking at large state coverage programs - Medicaid, state employees, and state public health - and seeing how they might further facilitate and use health information exchange. We also asked them for a presentation on current state progress in the creation of exchange networks. A part of the reason that Jim and I were asked to be the initial chairs was the breadth and success of the work that is ongoing in Tennessee and Vermont in creating these. Speaking for Tennessee let me take a personal moment to publicly thank Mark Frisse and Antoine Agassi, who are both here, for their great work along with many others in our state.

The Alliance will meet several times this year, and plans to have draft reports by the end of the summer on each of these subjects.

This State Alliance has limited time and budget, and is not intended to be the last word on the subject by far. I do believe that if we can keep our Commission and its taskforces focused in some well-defined areas we can make progress, and we are both committed to making a success of this effort.

As I said at the outset, I'm not an eHealth expert. Where I can claim some expertise is in the art of getting things done; getting the right things done. I've had the experience of starting a company as the sole employee and growing it to several thousand. And I've spent the last decade and a half in the public sector, trying to figure out how to actually make things happen under that set of rules.

I want to talk with you this morning about getting things done, and I want to challenge you to think about how we get things done in using and exchanging electronic health information in some new ways.
I'm going to challenge you to simplify.

This is important stuff. Information technology has the capacity to vastly improve the quality and control the cost of care in our nation. And yet we underused it terribly; health care is still a cottage industry in many respects, and unless we bring that cottage industry into the modern era - not in its medical technology but in its organization - it is going to bite us.

The frontier in modernizing is not technical, we have too many technical tools, not too few. The frontier is in how to actually make something happen in the vast sector of our economy that health care has become. There are twenty thousand very smart and well educated people at this conference in New Orleans, but I'm concerned that we are mired in the "paradigm du jour" business; I can't remember whether it is Personal Health Records or RHIOs right at the moment. We're gotten ourselves in the complexity business, which is never good.

Put plainly, my thesis this morning is, "Enough with the grants, enough with the conferences, enough with new paradigms, enough with the pilot projects; this is good stuff; how do we actually get health care professionals and organizations to use it?"

This shouldn't come as a surprise to anyone: the task of leadership is almost never problem solving, but rather finding common ground on which diverse ideas and interests can progress.

eHealth is important for many obvious reasons, but let me offer also one less obvious one. In this new century, we have as a nation what seem to me to be a whole new class of problems: eHealth, the health care system as a whole, or to take an entirely different sector, things like energy independence in a global economy. These are a new class of issues because they are of a complexity and an entanglement with the economy we haven't seen before. There are some things that government is good at; solving these new problems is not yet one of them. We must change that, though, because solving these problems needs the standing and strength of government to get the right things done.

The less obvious reason that eHealth is especially important is that it is likely one of the most tractable of these problems, and I believe that in progressing there we might point the way to tackling some of the even more difficult ones that await us.

Before we begin, let's step back for a moment and look at the argument for eHealth.

We have a very expensive health economy today; 16+% of GDP as we speak, on its way to 20% and more, still something like 50 million Americans who lack insurance. The next highest nation, with universal coverage, is at I believe 11% and growing more slowly. There are still some companies and some unions and some advocates who couch the problem with a straight face as simply one of who pays, but they are getting fewer and farther between. The cost of our health care system has become a significant competitiveness issue for the American economy, and will increasingly drive jobs overseas.

Our system is first class in terms of convenience, but very middle of the road in results; our health indicators are in many cases worse than those in economies that spend far less. This is America, the land of efficiency and ingenuity, why should we put up with this?

We clearly have to do at least two things:

First, we have to alter the economics of health care. Any student who has finished Economics 101 in college can predict what will happen if an anonymous third party pays for incidents of service, not for results.

And second, we have to forge a system that is much more centered on the individual. My mother is 86, is in reasonable health for someone of that age, and has six separate doctors who not only communicate rarely but on occasion countermand each other.

Altering the economics and centering the system on the patient - defragmenting it. The reason that eHealth is so important is that you can't do these things without it. Organizing and communicating health information simply and to each part of the complex system of health care is an essential tool that our country needs in its toolbox to succeed.

It is time to move eHealth out of the laboratory and into the real world. To do that, there is going to have to be some central direction and driving and our federal government is about the only place that can happen.

Many of you in this room remember as I do when President Kennedy spoke to the nation, and set an audacious goal of putting a man on the moon before the end of the decade. We all swelled with pride and purpose. Now suppose he had added, "And to make this happen I'm going to let a thousand flowers bloom; I'm announcing a grant program to fund research on how to do this and pilot programs in states and on campuses across our great nation." We would have all been suitably deflated, and would turn our attention to other things.

The point here is that to have a chance of success we have to move beyond this tinkering around the edges approach of grants and pilots, make some choices, simplify our focus, and move ahead. This is something that likely only the standing of the federal government can accomplish.

How do we do this? I want to outline for you three things that I believe we could do to move this effort forward.

First, we need to establish a set of simple standards that can serve as a toolbox. I want to use the internet as a model.

Second, we need to reduce the size of the landscape that we are working with; to concentrate on one area and work through the problems there. I want to suggest the management of prescription medications - and ePrescribing in particular, although there are certainly others.

Third, we need to require the integration of information technology into the basic day-to-day operation of the practice of medicine. The challenge is to move beyond early adopters and those willing to experiment and into the real mainstream. Without this penetration, we have nothing. In Tennessee, if Vanderbilt wants to incorporate sophisticated IT in its healthcare practices, as it does, that is great; what I really need though, is Family Practitioner Dr. Jones who is using paper records up in Goodlettsville to be a part, and there we're not even close yet. I'll suggest some ideas on how this might be jump-started.

First, to establish a simple set of general standards that can serve as a toolbox.

I've given one other speech on the subject of eHealth in my life, about a year ago, much shorter and to a much smaller but similar audience back in Tennessee. One of the things I mentioned was the need for standards, and I expressed the opinion that we had a huge successful example right in front of us, the internet. The internet is built on simple and universal protocols and a process for defining and updating them, the RFC process. After my speech, a couple of the attendees assured me that this field already did have protocols, that HHS had been very supportive of standards, and I should have my speechwriter go look at HL-7 and RIMs and ANSI standards for billing and so on.

Since I'm my own speechwriter on this subject, I did so, and what I found was a vastly more complex, less specific and less stable set of standards than I was advocating. I talked to some practicing systems people, and they told me that while the general outlines offered by HL-7, for example, were very useful, the state of the art was that you pretty much developed an information exchange for a specific version of the standards and a specific set of users, and that the standards generally did not work well across different versions or with systems with which you had not had previous conversations.

Let me say that there has been progress since last year, and I acknowledge that the HITSP standards published last fall are a real step in the right direction in providing an overarching encyclopedia of standards. However, the basic description of high complexity still stands. I counted 10 separate standards documents in the laboratory results reporting section alone; 24 in the biosurveillance section.

As one person engaged in health IT put it to me, "The good thing about standards is that there are so many of them."

In contrast, just think for a moment how simple and highly specific the internet protocols really are. If your email server wants to send an email message to another, it connects using the universal TCP/IP protocol to a specific port, port 25, on the other computer. The other computer says, "2, 2, 0, Space, Its Domain Name".

Your computer then says, "H, E, L, O, Space, Its Domain Name." and the other computer replies, "2, 5, 0, Space, Hello"

You then say... and so on.

It is an almost absurdly simple and specific way of communicating, but that standard serves up billions of email messages a day, it now easily accommodates secure messaging, and most important, it allows two computers anywhere in the world to communicate arbitrarily complex documents with no prior arrangements.

I've just described a communications standard - SMTP; now consider a content one: World Wide Web pages. When Tim Berners-Lee invented the World Wide Web, wrote down a very simple tool for describing structured documents and for extending them using those links we all click on. Again, that tool - HTML - is almost absurdly simple; you can teach a willing 14 year old in an hour how to make up simple web pages from scratch with a text editor. The first web page ever written will display just fine in my new copy of Internet Explorer 7. In setting down a first simple standard, he didn't try to anticipate Amazon, or Google, or iTunes. He didn't try to involve every likely user of such a web in the design process. He didn't even try to specify the security techniques that now make online banking and shopping possible; that came later. He invented some simple tools that allowed his creation to take its first steps, and with those simple tools a million others quickly took his creation places he - no one - could ever have planned or imagined in advance.

I'm certainly aware that there are in this room professionals from the various standards bodies, others who have committed a great deal of time and energy working with them, and yet others who have financially supported this activity. I'm not being critical, I truly believe what you are doing is valuable.

In software terms though, it's as if you're being asked to write very detailed specifications for Version 5.0 of something before Version 1.0 is up and running. As the years go on, we'll get to much more complexity, to Version 5.0 and 6.0 and beyond, just like the internet did, but it will be built on and grounded in what we have learned and invented in the real world and not from trying to divine the future or involve every known interest at the outset. We need to simplify and execute: simple standards; simple communications protocols, and simple tools for structuring data, Version 1.0 out the door and into the customer's hands.

The internet is a great model here, let's learn from it.

So my first point is that we need some much simplified standards to use as a toolbox. My second is that we need to pare the immense problem of eHealth down to one that mere mortals can attempt; to cross the river hopping from rock to rock.

The information associated with health care is complex in their own right, and the health care sector is enormous. We have to break this problem down into manageable pieces to have any chance of success. To me, that would take the form of picking an area of health care and pushing forward to implement a solution widely in that area.

While some might see a narrowing of focus as a retreat from the large goals that have been widely articulated, I don't: I see it as real progress. Success in a complex environment almost always results from establishing a beach-head; get something working, get something established and then expand its reach. Success is contagious.

There are several areas that we might consider as a start.

We've established in the Memphis area in Tennessee through Mark Frisse and Vanderbilt what I call in shorthand a "free text" regional approach to making information available, and I believe Microsoft has just acquired a company that is active in this area as well. Another important area is the management of very sick people and people near the end of their life.

But the area that is most intriguing to me as a beachhead is ePrescribing, for several reasons.
It offers meaningful improvements in the quality and cost of care; reducing errors, helping ensure compliance, and attacking fraud.

It is conceptually simple; you deal with a limited, known universe of products and transactions.

It cuts across the entire spectrum of patients, doing limited, simple things for nearly 100% of patients rather than delving much more deeply and encountering much more complexity with 2% or 5%. You touch nearly all patients, you touch nearly all doctors.

It raises and requires practical solutions for many of the issues of confidentiality and patient identification that await us.

It forces us to confront the challenges of widespread adoption; to make it work we need to sell a lot of down-to-earth practitioners who have no inherent interest in eHealth except as it positively affects their practice and their livelihood.

I've described two ideas: simpler, more stable and more specific standards for data exchange, and establishing a working beachhead. The underlying idea here is keep planning and thinking about the future, but to simultaneously get Version 1.0 working, widely used, gain experience, and learn from that to extend it. It doesn't have to be perfect or comprehensive any more than DOS 1.0 or Word 1.0 was perfect or comprehensive.

The third principle centers on how we incorporate what we do into the mainstream, day-to-day business of delivering health care. Aside from early adopters and true believers, how do you get ordinary, mainstream health providers to use this technology, how do you establish a reason powerful enough to compel large numbers of them to invest their time and resources and participate.

The frontier in getting practitioners to join is likely the physician practice, and doctors and nurses are notoriously conservative and difficult to penetrate with new technology that doesn't directly affect their practice. They are on the whole reluctant to change behaviors they've learned over the years, and reluctant to invest in things that don't have tangible short term returns.

If we want to do what I have argued for today - let's say specifically to get an ePrescribing 1.0 system up and running - we have to establish some clear incentives to do so. Health care is just too big and diverse to have any hope of depending on a voluntary model, or on arguments about patient care or what happens if there is another Katrina. Our entire health care crisis is like one slow-moving and prolonged Katrina; a glacier rather than a hurricane, harder to see it happening, but just as powerful and just as dangerous.

As with everything, one of the easiest and best incentives is the incentive that you don't get paid unless you do it. The U.S. Department of Health and Human Services is easily the biggest purchaser of pharmaceuticals in the nation; suppose they mandated that at some time certain in the future they would no longer pay claims where they couldn't take the claim and go electronically with our simple and universal protocol and find the specific instance they were paying for in whatever database system we agreed to use.

In other words if I am DHHS, I say, "What I am buying from you with respect to filling a prescription is now threefold: the drug itself, the professional and business expense of dispensing it, and the placement of appropriate clinical and administrative information regarding it in an agreed-upon and widely accessible location."

If DHHS were to require this, the Blues and major commercial insurers and intermediaries would quickly do the same; the benefits would be enormous. As to maintaining the databases themselves, I believe there would be no lack of volunteers to set up such databases; once you have really simplified and standardized the interactions, it isn't even that expensive. The framework for this exists in what drug chains are already doing. Even for those who don't use a third party payor, who pay for drugs themselves, they still overwhelmingly buy them at pharmacies where computers are integrated into the workflow, and it is simple to incorporate their information as well.

If such a strategy were to be adopted, there would be areas that need cleaning up in the law. That is an area that our NGA Committee is looking at, and may be able to contribute to.

So we might begin establishing a clean and simple database working from the payor's side. How do we now get the providers to use it? And how do we move the input of data upstream to them as well, with all the attendant advantages in completeness and accuracy?

IT is widely used in individual hospitals today because it is integrated into the workflow; you can't order a service any other way. How do we integrate into the workflow in other places like a doctor's office?

Here's one idea: use the power of authoritative "best practices".

Suppose that an authoritative body - it could be the accrediting bodies, for example - specified that it was a "best practice" for a provider where possible to familiarize himself or herself with the pharmaceuticals now and recently being taken by the patient. That would in fact be a "best practice", and one which it would be reasonable to encourage as such - if there were a practical way to do it. We've been talking about practical ways to do this for the past ten minutes.

Many practitioners will try to correspond to best practices where they can as a professional responsibility. The defining of a "best practice" in this regard also engages the power of defensive medicine in a constructive way for a change - if a "best practice" is not followed, that failure can be an element in potential litigation - your malpractice carrier is going to want you to do it as well.

There are suddenly multiple good reasons to play: it's good medicine, it's practical and easy, and if you don't it could cost you.

How would a practice actually get this kind of information easily and inexpensively?

Again, inventing as we go, imagine there is a web-based service that a staff member could access that, with proper credentials and patient protections, would provide a page summarizing the recent drug history of the patient. It's done via the web so that there is no issue of software to be learned or maintained or bought, it uses something virtually everyone has - a computer with a browser. That page comes in a printable version, the printed sheet is attached to the chart along whatever else the practice does for a visit, and all the information is right there for the provider at a glance.

That simple sheet of paper would catch an amazing number of medication errors, of duplications, and of fraud. It could alert physicians to new information - the Vioxx issue, for example. It could recommend best practices.

I'm not in the least concerned with who might provide such a service or even that it would cost the practice anything: if I were the CEO of a pharmaceutical company or a payor, I would do almost anything to be the provider of that sheet.

When the practitioner goes to write a prescription, he or she will still likely want to do so longhand - a PDA in every doctor's shirt pocket is still a long time off. It's not a big step to have new and refill prescriptions written on that piece of paper, and to have them entered back on that computer by the office staff, where you can get an immediate check for interactions, for correct dosages, for compliance with an insurer's formulary, and so on. Refills are already managed in the back office as a practical matter, and making the refill process more effective and efficient would be a great start.

The sheet goes into the plain old paper medical record, the good practice requirements are addressed, compliance is documented and defensive medicine does some good for a change.

I've been inventing ideas on the fly this morning, and have talked in very concrete terms. I talked about specific data protocols, one specific application - ePrescribing, and even specific pieces of paper in the medical office.

That may seem like an oddly detailed and technical discussion for a Governor to be making in an address like this. But I spoke in specifics because that always seems like a useful way of getting down to business. For those of you who write a lot, you know how much the act of putting actual words onto paper clarifies and makes concrete your thinking.

As I said at the outset, I acknowledge that this room is full of people with much more depth and knowledge of this subject than I have. There are plenty of people here who could take any of these ideas I've served up and improve them or show how some alternative is better.

Behind this presentation however are a few underlying principles from an experienced practitioner of the art of getting things done; a few thoughts as to how we might break the logjam in this field and start moving something that can truly improve health care into full being.

I do ask you to consider those. What I ask you to take away from this and consider is not all these details and invention, but rather three principles:

  1. that we have to simplify, make concrete and make stable the standards that we build on - like the hugely successful example of the internet;
  2. that we should establish a beachhead somewhere and not try to win the whole war at once;
  3. that we can't depend on experimenters and early adopters, we have to make it attractive to play and difficult to not play for everyone concerned.

Whenever you propose simplification and slimming down, you open yourself to the criticism that you're naive. If you're in my field - politics - you open yourself to the criticism that you're taking the politician's approach of putting complex issues on a bumper sticker. That is not what I am doing.

I have found all my life that it is harder to simplify than to make things complex, harder and vastly more rewarding.

If you take nothing else from this morning, I want you to leave here believing that there is great power in simplicity and focus.

Jim Collins from Stanford wrote a management book a few years ago called "Good to Great"; I suspect a good many people in this room have read it. He followed it up about a year ago with "Good to Great in the Social Sectors". In that follow up he asks the question "Based on the return to the public shareholder, what is the most successful company in America over the last 30 years."

People guess Microsoft, or GE, or maybe Amazon or Google or some other high tech startup. The answer is Southwest Airlines. That basic, simple, low-cost airline in a generally terrible business has economically outperformed every high-flyer, every conglomerate, every merger, every exciting New Thing in America.

If there ever were a testament to the power of simplicity and focus, well-executed, it is Southwest Airlines. Limited routes and cities, one kind of airplane, no reserved seats, peanuts, no interline baggage transfer, you can only buy your ticket from Southwest. And they represent not the best performance of any airline, but of any company in America. Simplicity is strength.

I hope I've given you this morning some things to think about. Thank you once again for the honor of being here, and thank you for all you are doing and will continue to do to make better the care and the lives of our fellow Americans.