Jen Colamonico: Welcome to HMAS vital viewpoints on health care concise conversations with experts that identify practical solutions to make healthcare and human services work better. I'm your host, Jennifer Colamonico, and I'm thrilled to be your guide as we explore new ideas for solving challenges that confound our uniquely American systems. Charged with delivering health and health care in a world that has far too much information and far too little wisdom, we'll aim to keep it simple, frank conversations about what it really takes to reimagine these systems of health and health care. Our HMA experts know how things work and don't work, and they have viewpoints on both the problems and solutions that are born from that experience. Vital viewpoints on healthcare is not just another podcast, it's your window into the minds of those steering us toward a healthier future. Subscribe now and together we will explore the hard-earned wisdom that could change the way you think about your professional challenges. Ryan Howells is a nationally recognized digital health policy and interoperability expert based out of the Levitt partners Washington, DC office. He regularly works with the White House, Congress, the Department of Health and Human Services, Veteran Health Administration, and other agencies on digital health initiatives. Since 2016, Ryan has led the CAIRN alliance, which has advanced consumer directed exchange using fast healthcare interoperability resources application programming interfaces, otherwise known as APIs. CAIRN's work has been implemented in production across the United States, named as an industry best practice in multiple federal regulations, and received a World Changing Idea award by Fast Company magazine. Ryan is our go to person on all things digital health policy and has really been advising not only our colleagues, but our clients for years on the digitization of healthcare data and all that that means. So, Ryan, I am thrilled to have you on the podcast today. First of all, you know, how did, how did you get started? What first sparked your interest in healthcare technology, digital health? Where did your journey begin?

Ryan Howells: Hey, Jen, great to be with you today. Well, it's kind of an interesting story. So, when I was graduating from graduate school, I'm sorry, when I entered graduate school, I had an opportunity to be able to see the rise of the Internet, and that sounds like I'm old, and I am so. And as a result of that, one of the things that I was working on while I was there as part of what's called an administrative residency program, was finding out really what was going on on the Internet. Now everyone had day jobs. I was doing this residency and I was the only one that had the patience to watch the 14 four modem like load the pages. And so as I'm sitting there for literally hours on end trying to load, like, you know, a few dozen pages that take seconds now, I was thinking to myself, this is transformational. Like, this is going to change the world. And I know that sounds, you know, maybe trite or crazy, but I literally believe that because when I was looking at the Internet, I was seeing all of these companies that were starting up in healthcare and doing all of these amazing things that I knew needed to be done. And they were actually the first organizations that were getting it done. And so when I went into her chief operating officer at a very major health plan in the West coast, and I said, we need to pay attention to this, kudos to her, she listened. And as a result of that, we started to build out the first Internet initiatives anywhere in the country. Things like claim status and provider directory, things that we take advantage. We're still trying to get right, for the most part, but we, we know that it's something that's easily accessible today. But in the late nineties, that was a brand new thing. And so since then, I've had a love for digital health technology, where it's going to take us and kind of the future. And when I came to Levitt almost ten years ago now, that has been able to take place now at a national scale, which I'm super excited about, and working with private and public partners to get this done.

Jen Colamonico: Well, and that's sort of the irony, right? Is like, on one hand, we've made such tremendous progress in healthcare, really just in the last couple of years. And I know you've had a big role in that. On the other hand, healthcare is always so far behind because, you know, this promise that you just described is like, yeah, we've all lived it in other parts of our life, and yet most of us don't live it in healthcare, don't experience it. So, you know, at the risk of kind of stating the obvious, I mean, why is this such a big deal for, for patients, for people who could kind of experience a different sort of healthcare system if this information was all kind of where it should be on the Internet?

Ryan Howells: Yeah, well, look, the quick history, if we continue to pick up from the late nineties, is that was really the time when the Internet took off in the early two thousands. And when that happened, it took another ten years for healthcare to pass the high tech act, Congress, I should say, to pass the high tech act and for it to be implemented in healthcare. And then it took another decade to be able to digitize the healthcare records we were on, folks may have forgotten, in the early 2010s, we were still on paper for the most part, and you would still do that across. And then we've been able to make that happen. And now we've digitized the healthcare records. And now for the last five to seven years, we've been trying to help to get the data to move between entities. There's been kind of older ways in which to make that happen over the last decade using healthcare specific technologies, but we're moving towards Internet based technologies, like what's called application programming interfaces, or APIs, that actually enable this to be able to be found on any app of your choice. So we're moving to an app based economy in healthcare at scale that's never happened before. And so you've seen what app based economies do for our consumer life, and now we're going to see what it does for healthcare. We're going to be able to now intervene with specific measures for specific disease types and specific aspects of their life where we've never been able to before, involving both the individual patient, the consumer themselves and the provider, and having them have an opportunity to have that conversation where they've never been able to have that before because the digitized data wasn't available.

Jen Colamonico: So why has it taken so long? And is it HIPAA? And why is HIPAA so kind of misunderstood in this context?

Ryan Howells: Well, everything takes long in healthcare as folks know. It just does. And the only thing that really scales in healthcare is federal policy, and that's what requires everyone to get moving in the kind of the same direction. But as Governor Levitt likes to say, as you know, Jen, like, the public sector can't do this by themselves, and the private sector can't do this by themselves. So how do we figure out a way where both can work together to scale these technologies? And so, um, yeah, I think there's. There's some degree that HIPAA has been a barrier for this, um, for this scaling. And. And part of that has to do with the fact that, you know, data sharing used to be optional. I couldn't hoard all the data if I wanted to, and I didn't have to share it with anybody that I needed to. Uh, but the 21st Century Cures act that was passed at the end of the Obama administration in 2016 changed all of that. It actually made data sharing mandatory. And once it makes data sharing mandatory, everything changes at that point, because now it's not whether you have the data or not, it's actually what you're going to do with the data, and that's going to make it far more valuable for data holders and for those who use it, like providers and for patients. So that's where I see the miracle of all of this happening, is that now with the mandated data sharing, with the opportunities for providers or patients to get access to all of the data that they need in order to deliver the best care possible, that starts to really change things over the next decade for the benefit of all.

Jen Colamonico: So we talked about how it takes a long time for things to change in the federal government, but progress has been sometimes slow in the private sector as well. As you said, they're an equal and important participant in making these changes. So what have the barriers been in the private sector that you've experienced?

Ryan Howells: Yeah. So there certainly has been a ton of money that has been integrated into the private sector from the vc world, and we appreciate that. I mean, that helps, obviously, with innovation. But I think one of the biggest challenges, Jen, is back to access to data, right. So one of the problems for these digital health companies, they certainly started really well and many of them had incredible exits, but, um, a lot of them have fallen off their highs. Um, whether it's because of after Covid or any of the other things, they're, some of them are down 70% to 90%. And one of the reasons for that is because of this access to data issue. So today, those digital health companies have to knock on everyone's door and get a data use agreement and go through a security review and go through lawyers and all this stuff to try to get access to this health information. And that is super important because it relates to federal policy related to HIPAA, but it's also super laborious and is super costly and it's super hard and, uh, it's difficult. And so, um, if I am a provider and I'm treating Jen, I want to make sure that I have access to all of Jen's medical history, period, full stop. And, um, we recognize the difficulty in doing that. There's all these, like I said, data use agreements to try to make that happen. But if I'm a provider, I should have, uh, based on HIPAA and minimum, minimum necessary, the ability to access that health information. We just don't today. And so that's the reason, I believe one of the reasons you're seeing a significant drop off with digital health companies. But as we move to more of a mandated data sharing model, we move towards more of a API, Internet based model that starts to change things dramatically, because now we can use Internet based standards. They're more secure, they're more privacy centric, they're more consent driven, they're more needs based, all of those things. And now we can start to layer on these applications that provide all kinds of value for, again, both consumers and patients. And that's the, I think the big change that we're seeing in the marketplace right now. And I think you're going to continue to see it. I think it's just the beginning. I don't think that we are. I guess the beginning of digital health was really digitizing the records. We're probably somewhere in the middle at this point. And now we're going to move into more of the innovation economy where these three things really, the APIs, the apps and AI, can sit on top of this data and make it extraordinarily useful for people. Those three things, I think are going to be absolutely transformative over the next decade.

Jen Colamonico: So you mentioned AI. I want to come back to that, but I just want to make sure I'm getting the flow here. There's app developers out there. They came up with a lot of great use cases, but the data really still wasn't available. Some of them have hung it up, others are sticking it out. I guess my question is. So then there's who holds the data right? It's the providers, it's this hospitals, the docs and the insurers. So is it just that the use cases haven't been compelling enough for them, or it was. I mean, you mentioned it's tricky, right? It's hard to do this. So is it just kind of the effort outweighed the potential benefit?

Ryan Howells: One of the challenges that we've had is the fact that if I am a new patient and going to a new primary care physician, I want to provide that primary care physician with all the data that they need to see. The history of who I am. We just recently moved about three years ago and I had to choose a new PCP and they had no idea who I was or what my health history was. I am in this space, Jen, and it was still difficult for me to try to aggregate all my health information. Now, do, does, should my primary care physician actually have access to that data on my behalf? Absolutely, for sure. And they should be able to go out, query a network and on multiple networks and be able to pull that information back in. But should I as a person also be able to provide that to my PCP when I actually register online and find a way to be able to fill out all the paperwork anything else that I do? Absolutely. I should do that, because one of the things I think we forget, Jen, is the only constant in healthcare is the patient. They’re the only one that is constant across the entire care continuum. And so from a patient perspective, we don’t want to put that burden on patients, but certainly we want to provide that option for them so that they have that information and can share it. And so, when you talk about these digital health companies, one of the things that I think is going to happen over the next decade is you’re going to see those type of workflows get integrated with the actual core payer provider workflows that we have today. So the quick story on this is GoodRx, actually. So GoodRx started as a actually business to consumer company, and it was like a miserable failure. They were trying to get this information out. They did all these ads. Nothing actually worked. And then all of a sudden doctors started seeing these GoodRx ads and they said, wow, this is really interesting. How do I actually figure out a way to get those, that this prescription medication cheaper to my patients because they're not fulfilling their prescriptions because it's too expensive. And so they call the company and they said, do you have anything you could provide to us, maybe a little small business card that we could give to our patients so that they could know that they have cheap alternatives out there for us to be able to access this information? That's where those little yellow cards came from. It went into every provider's office in the country, as far as I know, and now they have something like 30 million patients on their platform every single month, same thing. I think, Jen, that's going to happen here with digital health. I think what's going to happen is that patients and others are going to be empowered with this information. And then as these use cases become really valuable for patients and providers, it's going to get integrated into the core workflow with the patient's consent. And that ability to link both patients and providers together with access to their longitudinal data unlocks all kinds of really great opportunities.

Jen Colamonico: So as long as it's easier than filling out the clipboard every time, you're going to achieve that convenience for patients. And then it seems like really the magic for it, understanding how much the doctors are at the center of this and understanding what motivates them is probably that secret sauce. So that was a great story. Which takes me back to AI right. AI right now we're in a bit of a space where I think a lot of providers are maybe nervous or skeptical or feel a risk of being displaced, but there's certainly tremendous potential here to take burden off of them, to help connect those dots. So maybe just talk a little bit about how you see that playing a role, that important third piece that you mentioned in making this happen.

Ryan Howells: So obviously, AI has been around for a long time. I think the new portion of AI is this idea of really consumer facing generative AI and what that actually looks like. I think that there's tremendous opportunities there. But I also think maybe this is a spicy take, Jen, that a lot of this is, we're definitely at the top of the hype curve. AI does have an opportunity to be able to do things that we've never been able to do before. But how you monetize that, how you provide value, where that actually integrates in the workflow, does this become another feature in the workflow in terms of how this operates? And is it just that we have opportunities to provide better information? That's still an open question. And then obviously, how do you regulate it? Or can you regulate it? That's a really still significant question. Some of the smartest people on the planet still are very open with the fact that they don't know how Genii actually works and they can't see common ways in which the information that's being provided can be able to be able to be developed consistently. So the hallucinations problem is a big deal. And I think they're making progress, but it's still very early and so we have to be careful. I think the transformative, there are certain use cases that are transformative. Right. Ambient listening, for example, for a doctor's office. I was just in my doctor's office the other day and she's like, do you mind if I record our conversation so that I don't have to do these notes at night? Course not yet. Go for it. And doctors are now starting to shift their opinion of digital health from burden to burden reducer. Right. And so that's what I think is going to be the transformative piece, which is I may not like my EHR and doing all this data entry to know I actually love this technology because it's actually reducing my overall burden. And that's where I think apps, AI and the opportunity for APIs to really transform the industry is going to come from, is the fact that it's going to move to more of a burden reducer than burden providers.

Jen Colamonico: Well, right. I'm vigorously nodding over here. I mean, I feel like that's the thing that when technology companies come into healthcare, they sort of see big shiny objects and we're going to invent new things, or, and it's like, no, just make it simple, man. Just like, make it easier. Because it is so stunningly not easy sometimes to do basic things. So, you know, patients and providers share, you know, share that. I think that fundamental need to just make it easier. And so if that's, if that's what AI can deliver, that will be a game changer.

Ryan Howells: Well, gen two, it's not just make it easier, but let's stop doing stupid things.

Jen Colamonico: Yes, please, let's.

Ryan Howells: Let's stop filling out clipboards. You mentioned the clipboard, right? Like, why are we filling out clipboards when we spent $40 billion trying to digitize the healthcare environment? That's a dumb thing. Like, we should be able to have an opportunity where the provider and the patient have already have this relationship. They've identity proof themselves, and they can come into it in doctor's office, and either the doctor already has the information for them or the patient's provided it to them. Either way, the doctor has that information and I walk in and I just provide them my information. I sit down, I go in, and I have a great experience with my doctor who uses these apps and AI and APIs to then be able to provide even better, uh, more informed, uh, options for my treatment plan and, and do care coordination behind the scenes. I don't have to worry about that. I, that's where we're going. We haven't been there to really a great degree. We've needed a lot of people to try to help us get there, but we're moving to more of an environment where we can get there at scale and not necessarily need as many folks in the middle or companies in the middle to help us do that. More of connections that could actually help the scale.

Jen Colamonico: This seems like a great jumping off point for my favorite question. So if you had a magic wand to what is the one thing that you would fix to, to get this on track to, to allow us to, you know, stop doing the stupid things and start doing the smart things, what is the one thing you think would be fixed that would really just start a different ripple effect to move this forward?

Ryan Howells: I think, Jen, though, one thing is vision. And what I mean by that is I don't think we have a broad enough vision in healthcare to be able to fix all of the issues that we have. So that vision is, I want to get the right data to the right person at the right time in the right place. To fix the right problems, to get the right outcome. If we can do that, we can fix all kinds of problems. In healthcare, the challenge is the silo ness. That's not a word, Jen. But the fact that healthcare is so siloed is impacting our ability to make both individual and collective change at scale. We need to fix that. We need to think more holistically, cross systems, cross organizations, cross people, cross workflows and cross data silos to be able to help resolve the myriad of issues that we have in healthcare. There isn't one sector of the economy that can do that. It's going to take all of us.

Jen Colamonico: So the vision would be that to go, I like silo Ness, by the way. That should be a word because it absolutely describes the experience. The vision would be to go through silo thinking, to being part of a problem resolution like that they are a part along with other parts. And to do that, it's not all happening within your walls, within your four walls, within your.

Ryan Howells: Yeah. Look, I think collaboration and trust are going to be the two most important things over the next decade. And leading organizations, if they embrace those two values of collaboration and trust, I think they're going to win. And the reason I say that is because we live in a world right now, like I said, where data sharing is mandatory. We live in a world where price transparency is real. We live in a world that you may think that your competitors don't know much about you, but they know everything about you now. They know your contracted rates, they know exactly the data that you hold. They know all kinds of things. And that scares a lot of people. But that's a reality of the situation that we're in now. The question just becomes, can you be able to out execute folks in delivering better, higher quality service and outcomes than your competitor? That's really the main question. And can you deliver that in a model that allows for that massive collaboration and trust across trading partners? Are you going to make it easier for patients and providers before your competitor does? To me, that's the biggest question of all, and that's the question for the next decade, is where we go with that. And that's going to take a broader vision. I wish more people had it, Jen, were lucky enough to work for an organization where we work on these problems all the time, every day. And I'm grateful for that. I'm super grateful for that. But my hope is that more people adopt that vision of like, what does this mean for us as a country? Because we can't continue the growth that we've been experiencing in healthcare. It's just unsustainable economically, politically on all different facets of our life. We just cant continue the 16% to 20% of GDP type growth over time. Its just going to cripple us as a world economy. So lets do things better. Lets figure out ways that we can work together better than we do today.

Jen Colamonico: So that’s a scary place for a lot of businesses, right. Especially for CEO's or people who’ve been leading successful organizations for a long time. That's really a shift. It's a business model shift. It's a culture shift. So what is your advice to those who, let's call them the data holders, those who hold the information that needs to be shared, that needs to be usable? You know, what's the optimistic advice of what they should be doing to be ready for this? It's, you know, how does this become a strategic imperative even though it's big change and it's maybe a little bit scary?

Ryan Howells: Yeah, it's a great question. So there are a lot of data holders that are viewing these ONC and CMS regulations as kind of what I would call regulatory checkboxes where they're just saying we're going to get this done because the government told us to get it done.

Jen Colamonico: And by that you mean like the price transparency and the things that you mentioned earlier?

Ryan Howells: All of the above, right. Price transparency, the API interoperability rules, all of the things that have happened with digital health and with CMS Onc, all the things that have occurred that they’re just saying, yeah, were just going to have to get this done. There are other organizations, I guess there’s three types of organizations. There are other organizations that have no idea really what’s going on. What is this rule? I haven’t read it. What’s happening? I don’t understand. And they’re just caught up in the whirlwind of work. I don’t mean disparaging at all. Its just that they have a lot of things going on. This isn’t necessarily top of mind, but there’s a third category and they’ll move based on where the, where the opportunities may lie. That's that squishy middle. But there are other organizations who have embraced this, who said, listen, price transparency is real. We're going to make this information valuable to our patients. APIs are a real thing. We're going to make this valuable for developers to actually build on top of the data that we have and start partnering them in a new and innovative way. So we as an organization don't have to build all these solutions, we can actually work with others to build them. We're also going to work with partners to be able to train partners to say, your life's miserable because you don't have access to the data. Our life's miserable because we don't have access to the data. Let's figure out a way to do this in a more modern, Internet based way, using these APIs that will help us. One of the prime examples of that, Jennifer, is the idea of prior authorization. So the CMS rule requires that electronic prior authorization be in place by 2027. Early adopters have shown a 200% to 400% return on investment for this electronic prior authorization. So that's as, and this is to the business themselves. The organization itself is representing tremendous value from implementing this API. And it's jaw dropping the amount of opportunity because payers hate prioritization. Providers hate prior authorization, so do patients, but to some degree it's still required. And so how do we figure out a way to streamline it? And we're even talking to payers now, Jen, who are saying if we can streamline it and put this on an electronic chassis, we can start to measure, monitor this stuff and understand who's doing what when, have much more clarity and how that works, educate the provider community associated with that. And then let's start eliminating this. Let's just start taking it out of the system because it's not providing any value. And that, to me, that's where the exciting part comes in, which is let's stop doing the stupid stuff. Let's figure out a way where we can be able to really innovate on top of the data that we're not doing now. We're just transacting today. And that's just not where we want to be. We want to innovate and actually solve problems and deliver better care.

Jen Colamonico: Yeah, so the promise is less stupid stuff, more the stuff that matters. And being able to quantify it with data is what helps us distinguish between the two.

Ryan Howells: That's exactly right. Absolutely. Quantify it with data. Just real quick, Jen. Like social determinants of health, health related social needs. Right, big topic. Everyone believes it's a problem. I don't think that that's a conversation any longer. But we haven't had the data to show us how making a difference in people's lives. So we've got to figure out how to do that. We've got to figure out a way to standardize that on APIs. The gravity project and others are making that happen at scale which is great. Uh, but there's also this ability of, how do we exchange data between regulated environments, between HIPAA and the FTC? You know, the individual person is not in HIPAA, it's. They're in the FTC regulated environment. And so even if we get a national privacy law, we still have to figure out how we send data back and forth between regulated environments. That's going to have to come through consent and identity and the ability to send the data back and forth using more Internet based technology. So all of that happens because no matter who pays for health related social needs, private sector, public sector philanthropies, individuals, whoever that is, we still have to show demonstrable progress in why this makes a difference. I think everyone believes that it will. Everyone believes there's a need there. But to actually see the outcomes is going to be important for long term sustainability of that area.

Jen Colamonico: Yeah, well, it's exciting times. It's big, it's thorny. You've really been in the middle of a lot of huge progress. So we all are grateful to you for that and those who you've worked with in the CAIRN alliance. So we're glad to hear from you. And I think people should be left with a sense of optimism. And let's find that vision. Let's spread the vision so we get more people kind of in on the problem solving because we're there. We just need to.

Ryan Howells: Let's do it. Let's do it. In fact, just call us up, like, just if you want to be involved in this, like, if you want to be integrated, like, whoever you are, we'd love to have you at the table. There's just not enough folks thinking about true innovation and wanting to be early adopters of this. Jen. And again, we recognize this because of the whirlwind of your day job. But if you want to really be on the forefront of this, we're doing work in quality and social determinants and patient access to data and APIs and all these wonderful areas of the economy. And we need more folks to be able to innovate with us. So really come join the great party that we're having. It's awesome.

Jen Colamonico: The Vision party. Come to the vision party. You're invited. Excellent.

Ryan Howells: Let's do it.

Jen Colamonico: Thank you, Ryan. Always a pleasure to talk to you.

Ryan Howells: Thanks, Jen.

Jen Colamonico: This episode of Vital Viewpoints on Healthcare is sponsored by Levitt Partners DC Direct. Are you looking for weekly insights on health policy developments in Congress and in the administration? DC Direct, federal policy intelligence services help clients understand not only what key developments occur each week, but also explain why they matter. Visit levittpartners.com for more information. Thank you for tuning in to another enlightening episode of HMA's vital viewpoints on healthcare. We hope today's discussion has sparked new insights and perspectives. To learn more about our esteemed guests, please be sure to visit healthmanagement.com podcast. Until next time, stay informed, stay curious, and keep searching for the wisdom that will help to transform our healthcare landscape. This podcast was produced by myself, Jennifer Colamonico, along with Tiffany McKenzie, in collaboration with our guests. The content is the property of health Management associates.