Dr. Don Rucker, National Coordinator for Health Information Technology at HHS

Dr. Don Rucker – National Coordinator for Health IT at HHS

[Music]

Mark Masselli: This is Conversation on Health Care , I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret, there have been more twist and turns surround ing
health policy this summer than a boomerang rol lercoaster at Six Flags. The
Senate’s recent marathon to end Obamacare came up one vote short after no
small amount of high drama over the Senate repeal - and - replace efforts.

Margaret Flinter: A marathon vote - a - rama took place in the Senate after Senator
John McCain cast a decisive vote to allow the discussion on the GOP
replacement bill to continue , recently diagnosed with an aggressive form of brain
cancer , many viewing the timing a s ironic considering the bill would take health
care away from millions of Americans.

Mark Masselli: After a whirlwind couple of days of discussion it was clear that a
handful of female Republican Senators were holding steadfast to their conviction
and they were certainly vowing not to support the GOP proposal which would
ha ve led to a real loss of insurance coverage fo r tens of millions of Americans.

Margaret Flinter: And once again , it was Senator John McCain who caste the
deciding vote . Joining ranks with Republican Senator Susan Collins of Maine ,
and Lisa Murkowski of Alaska , they all voted no on the Senate bill and essentially
killed the effort. The GOP effort to kill Obamacare has signaled yet another
victory for support er s of the Affordable Care Act which has certainly run a
gauntlet of legal and legislative changes almost from the moment it was passed.

Mark Masselli: And there is now a bipartisan group that has formed in the house,
40 house members joined the so called the Problem Solvers Caucus. They’re
working on a variety of legislative fixes for the Affordabl e Care Act which both
parties agree is called for . It will be interesting to see what outcomes this
bipartisan effort has , Margaret.

Margaret Flinter: And in the meantime , the health care industry continues its
transition into the digital world and ther e are some serious growing pains around
health information technology and that brings us to our guest today . Dr. Don
Rucker is the National Coordinator for Health IT at the Department of Health and
Human Services .

Mark Masselli: He brings tremendous cac he to the position and we're looking
forward to that conversation.

Dr. Don Rucker – National Coordinator for Health IT at HHS

Margaret Flinter: Lori Robertson will stop by , the Managing Editor of
F act C heck.org , but no matter what the topic you can hear all of our radio shows
by going to www. chcradio.com.

Mark M asselli: And as always , if you have comments please email us at
[email protected] or find us on Facebook or Twitter , we love hearing from you.

Margaret Flinter: We will get to our interview with Dr. Donald Rucke r in just a
moment.

Mark Masselli: But first , here is our producer Marianne O’Hare with this week’s
Headline News.

[Music]

Marianne O’Hare: I am Marianne O’Hare with these Healthcare Headlines.

Bipartis an seems to be underway in Washington . In the H ouse of Bipartisan
group some 40 lawmakers ha ve been meeting privately to hash out workable
solutions to some of the lingering problems with the Affordable Care Act . The so -
called Problem Solvers Caucus is signaling a willingness to reach out across the
a isle for policy initiatives that stand a chance of making it through the legislative
process , their first order of business stabilize the insurance marketplaces across
the country. The Trump Administration has threatened to cut off the cost sharing
subsid ies already in place for this year’s insurance purchasers . The insurance
industry has been lobbying hard against cutting off those funds , meanwhile
Republican Senator Lamar Alexander said his committee would begin bipartisan
hearings on stabilizing the in dividual health insurance market the week of
th
September 4 and urged fellow lawmakers to fund the cost sharing subs idies for
at least another year.

For the first time in history the Food and Drug Administration is planning to
regulate and reduce the amoun t of nicotine in cigarettes to levels they deem non -
addictive . The target reduction is 95% . Studies have shown smokers given less
potent cigarettes did indeed smoke less and showed fewer signs of addiction
than smokers using conventional cigarettes.

I’m Marianne O’Hare with these Healthcare Headlines.

[Music]

Mark Masselli: We're speaking today with Dr. Donald Rucker , the National
Coordinator for Health Information Technology at the Department of Health and
Human Services . He previously served as a C linical Professor of Emergency
medicine and biomedical informatics at Ohio State University and was Chief
Medical Officer at Siemens Healthcare USA . He started his informatics area at

Dr. Don Rucker – National Coordinator for Health IT at HHS

Datamedic Corporation where he co - developed the world's first Micr osoft
Windows - based electronic medical record. Dr. Rucker earned his undergraduate
degree at Harvard College, his MBA and Master’s in medical , computer science
at Stanford , and his medical degree from the University of Pennsylvania School
of Medicine . Dr. Ruc ker , welcome to Conversations on Health Care .

Dr. Don Rucker: Thank you, appreciate it .

Mark Masselli: You know I think it's fair to say we love talking to the coordinators
for ONC . We’ve ha d Vindell Washington on , Karen DeSalvo, Farzad Mostashari ,
an d going back to David Brailer 13 years ago when President George W. Bush
created the office . And there has been so much that’s happened in our world ,
now you sit in that seat and I’m wondering if you could talk about the current
state of health IT in this country , what you want to accomplish in terms of
reducing physician burden or enabling consumer access to their data .

Dr. Don Rucker: Yeah I think when we sort of look at the timeline mark s that you
have just outlined , most clinicians , almost all hospit als have the records
electronically . There are really two big issues that have percolated up , Congress
with the Cures Act that’s top of mind for Secretary Price , and one issue is just
these systems are difficult to use, part of which is an EHR issue , part of which is
really the broader surround . The second issue is people sort of thought that all of
this would sort of electronically communicate right . Our smartphones
communicate a lot better than it has . This is something that in the IT world we
call in teroperability , so that burden reduction , usability and interoperability are
really the two big go forward challenges that you know we're focused on .

Margaret Flinter: Well Dr. Rucker , you’ve experienced these inherent cha llen ges
of Health Information Te chnology from a lot of different angles certainly as a
practicing ER physician and an internist I understand . As a technology developer
you have made your mark on the corporate side , all big accomplishments . So
you have had a very front row seat at all o f these intersecting points in the h ealth
IT landscape , what are these inherent design challenges in building high
functioning h ealth IT systems and how will that experience and that knowledge
inform your efforts at ONC?

Dr. Don Rucker: So I think there are many , many sort of usability issues that sort
of get wrapped up in the colloquial I hate my EMR , some of which just starts with
interfaces , r u les , including some of the m eaningful use r u les . A lot of it is around
reimbursement , what does it take to co de a level 4 or 5 visit ; quality reporting is a
big new one . Everybody says well I can use my ATM card in pick your remote
corner of the world , but ultimately that’s a number . That’s a relatively
straightforward thing to compute about. We are talking ab out human biology
which as we know from DNA sequencing is inherently unique . So when you look
at interoperability I think we have had some good progress in data originally
generate d by a machine , so data for example from lab analyzers , CAT scanners

Dr. Don Rucker – National Coordinator for Health IT at HHS

or MRI that type of information I think we have had a pretty good run on , data
that requires human organization , a problem list . So I think that’s -- think about
the interoperability and the n of course with interoperability you are solving for
technical issues , you are solving for workflow issues all simultaneously , the
problem is they sort of have a multiplier effect.

Mark Masselli: Dr. Rucker , the Office of the National Coordinator is tasked with a
pretty heavy lift , helping the industry build interoperable , private and secure
nationwide health information infrastructure and you can say that if we're going to
achieve that goal we need to strip away various regulations and reporting
requirements that overburden health care providers . I’m wondering how easy is
that burden to reduce while at the same time improve capacity for a better flow of
health data .

Dr. Don Rucker: So one is the documentation concerns and how might one
address those. The second is the interface API concerns for institutional
accountabil ity.

Mark Masselli : Yes.

Dr. Don Rucker: We're working heavily with CMS to try to reduce provider
burden . I think it's worth understanding for people though a lot of these things ,
including for example even the level 4 and 5 codes, came because of Med icare ’s
fiduciary responsibilities to avoid fraud and abuse and I think we just have to
understand there is a yin and a yang to these r egs. I think HHS has to balance
those two things.

Margaret Flinter: Well Dr. Rucker , you had a recent p res s briefing a nd you’ve
noted at it that while the standing mission still remains intact at the Office of
National Coordinator there are two pieces of legislation that will provide important
guide posts for your efforts moving forward . One is the passage of MACRA and
st
t he other is the 21 Century Cures Act which earmarks I think almost $7 billion
for cancer research , more rapid drug and device development . Talk with us
about these initiatives and how you envision them shifting the landscape as well
as the mission at ON C .

Dr. Don Rucker: The MACRA Law is the law that replaces the annual [inaudible
10:09] this puts that on to a more permanent basis . It also took the outpatient
Medicare meaningful use and wrapped it into the merit - base d in centive program
provisions of M ACRA . There the issue really become s how do medical records
support quality measure reporting th at Congress has passed a number of laws
over the years and moved from volume to value in payment . The concerns there
of course are there are some different re gulatory requirements , there are some
complexities in reporting so that’s the MACRA part of the side of ONC’s
st
responsibility. The 21 Century Cures Act has a number of different provisions . I
would say the big areas for the Office of the National Coordi nator are definitions

Dr. Don Rucker – National Coordinator for Health IT at HHS

of what is interoperability , what is information blocking and what are open APIs .
So API is Application Programming Interface and that is really the software front -
end if you will or the software door into a system’s data , and mind y ou like real
doors there are keys and security and authentication , and the fact that it ’s a door
doesn’t mean you just get to enter , but it is a door with a computable address .
So those are big things in the Cures Act , each of those things needs definitio ns
because there is lot of complexity as you can sort of tell .

We're really working off of three use cases there . One is can patients , individual
consumers access their medical record by just pointing their app at their
provider ’ s URL and with the approp riate authentication get their data for
themselves , right, you know to always get your data by logging on to a provider
portal that may also tie you into providers where you would potentially want to be
able to get providers to compete for your business. The second use case is
since most care in US is actually not purchased by individuals but purchased in
large amounts by companies, agencies , can they with contractual protections get
data efficiently from providers in volume , right. So if I am xyz motor c ompany
and I would like to see the quality of care at five hospitals can I get that or do I
have to go in and try to sign something for everyone , have a huge amount of
work to do that . With open APIs you should be able to do that. The third use
case is j ust really the details of what an open API is . I would encourage your
listeners to think of them in sort of two classes. The first class is simply what
does that look like on a vendor , right . So if you buy your software product from a
commercial vendor what does the ability to have an open API look like and then
what does that look like from a provider . So if I’m a practice, I’m a hospital and
somebody says where is your open API , what does that look like , so that’s how
we're working through both MACRA to start with and the Cures Act.

Mark Masselli: We're speaking today with Dr. Donald Rucker , National
Coordinator for Health Information Technology at the Department of Health and
Human Services. You have noted health care needs to take a more Silicon
V alley approach to developing systems and we spen d a lot of time , a lot of effort
and I think many providers would still feel it's more like death valley rather than
silicon valley and I’m wondering if you could just ---

Dr. Don Rucker: The harshest compar ison they probably drew.

Mark Masselli: Unfortunately I think we -- and I am wonder ing if you could
describe the trajectory that you see by engaging that ethos into your approach .

Dr. Don Rucker: Health care doesn’t really sit in a competitive market e conomy .
Over the last 50 odd years of Medicare we’ve entirely decoupled what would in
microeconomics be efficient decisions . So when Medicare started setting prices ,
every single part of the efficient frontier of providing goods and services was
uncouple d from efficiency , so when we look at let's say a Silicon Valley kind of
thing w e are looking at it from a very , very funny historical perspective , we're not

Dr. Don Rucker – National Coordinator for Health IT at HHS

really looking at it from a pure market the way that Uber or a Facebook or a
Google . We're lookin g at it from this funny kind of policy - generated world , right,
because the deficit is fundamentally the lack of market information through
market prices , but when you look at the Silicon Valley approach , a lot more small
mobile devices , a lot of creativity about how things are being put together . One
example might be Google Maps. If you look at the number of apps that you have
on your smartphone that somehow use Google Maps, somewhere on there
whether it's a hotel or finding a bank where mapping tools com e in , right , so
they’re pointing to a URL and they’re getting a map back , right . So that’s an
open API in a Silicon Valley sense.

Now obviously in health care there will be some authentication . There would
actually be a contract , but if it's something f lyway , patients should be able to
access it and d eal with it as they desire . Right now I think there is a divide where
you have lots of health apps designed by Silicon Valley, but almost none of these
actually have access to what I would call medical data , right . Yeah they can
ac cess your Fitbit but if you are a 65 - year - old with four or five comorbid medical
conditions what you really want to access is your clinical information and you
know we're not seeing that in the apps space.

Margaret Flinter: Well Don, you do hold a very unique role . One, you have to
build a better h ealth IT infrastructure for the country and providers and
institutions , but also really help patients better navigate t he h ealth IT world . Tell
us about maybe some of the initiatives that you see really having an impact on
the consumer user experience .

Dr. Don Rucker: Well I think Congress I think is trying to get people back into the
spirit of shopping for health care , and private payers are sort of almost being
forced to do the sam e thing as well . And we see this with high deductible health
plans w h ere collectively anybody who is private sector employer has higher
deductibles and greater personal out - of - pocket risk . Right now it's very difficult
for consumers to shop because I thi nk for a variety of reasons , pricing is not
transparent, but as people shop and ask there will be some progress made there.
So I think on the consumer side it's really the need and the incentives to shop
with your high deductible health plan. You know co nsumer behavior is pretty
powerful , America is built on it . I mean you look at the entire brick and mortar
landscape , totally physically transformed by electronic shop ping. I mean every
mall in America looks different . Airlines, banking , pick your indus try , all of these
have been transformed , so I think health care is ri pe for that .

The other part that’s out here of course are API standards that make this easier
to write code against some of these EMRs . Every EMR has some internal
representation , right ? There is no general global model of what all clinical data
looks like, so nobody knows everything in the health care . So every system
represents the internal data differently . What can we do about uniformity of
some of these interfaces to get part of that information out , that’s the way you are

Dr. Don Rucker – National Coordinator for Health IT at HHS

going to be able get real clinical information that fields [ph] insight s , decision
support and can support consumer behaviors.

Mark Masselli: You know I was thinking Don as you were talking earlier about
the d oors and reminding people that they w ere n’t necessarily doors that you can
just easily get into , but the fact of the matter is what we're seeing around the
globe is that there are enormous breaches of h ealth IT systems and the recent
WannaCry Malware attac k crippled the National Health System in the UK and
there are many other examples , and I guess I think they’re wondering how
prepared is the United States health system to deal with this issue of data privacy
and security .

Dr. Don Rucker: You know I tend to think of security more broadly than health
care because there is lots of valuable data so I try to think of it more from a
computer science point of view . And so when you do programming , when you
setup systems , it is really a cat and mouse game. I me an th ere is just inherent
tension between good and evil there , but I think there are number of various solid
practices on data , on encryption . I mean we know a lot about security and when
you look at a lot of the ransomware , those things are going into kn own breaches ,
but again we I think collectively have to keep our guard up and make the
investments in these systems and the system designs to really protect the
information , but I don’t think there is a magic bullet here.

Mark Masselli: We’ve been speaki ng today with Dr. Donald Rucker , National
Coordinator for Health IT at the Department of Health and Human Services. You
can learn more about their work by going to HealthIT .gov or follow them on
Twitter at onc_healthit. Don , thank you so much for joining us on Conversations
on Health Care today.

Dr. Don Rucker: Thank you.

Mark Masselli: At Conversations on Health Care we want our audience to be
truly in the know when it comes to the facts about health care reform and policy .
Lori Robertson is an awar d - winning journalist and managing editor of
F act C heck.org a nonpartisan, nonprofit consumer advocate for voters that aim to
reduce the level of deception in US politics . Lori , what have you got for us this
week?

Lori Robertson: President Donald Trump sa id on Twitter that “ Bailout s for
insurance companies would end very soon if Congress didn’t pass the new
health care bill .” Senator Susan Collins said the payments aren’t a bailout “but
rather help people who are very low income afford their out - of - pocket cost .”
Trump actually distorts the facts in calling them bailout s. These payments which
do go directly to insurance companies , are made to reduce out - of - pocket cost s
for those who earn between 100% and 250% of the Federal poverty level and
they a re diff erent from the premium tax credits that reduce monthly premiums for

Dr. Don Rucker – National Coordinator for Health IT at HHS

those earning between 100% and 400% of the poverty level . Those eligible for
premium tax credits can choose to receive the credit in advance or claim the
credit the following year on a ta x return or a combination . The cost sharing
subsidies meanwhile are only available in advance . The payment goes to the
insure rs to lower the out - of - pocket cost including deductibles , co - pay s and
coinsurance . Those who qualify , automatically get a choice of plans that include
those reduced out - of - pocket ca ps. The Centers for Medicare & Medicaid
Services said that 10.3 million people had signed up and paid for a marketplace
plan early this year and 57% of them received cost sharing subsidies . That’s my
f act check for this week . I’m Lori Robertson, Managing Editor of FactCheck .org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country’s major political players, and is a project of the Annenberg Public Policy
Center at the Un iversity of Pennsylvania. If you have a fact that you would like
checked, email us at www.chcradio.com . We will have FactCheck.org ’s Lori
Robertson check it out for you here on Conversations on Health Care.

Mark Masselli: Each week Conversations highlights a bright idea about how to
make wellness a part of our communities and everyday lives. For all the people
in the world without limbs , acquiring prosthetics can be costly and out of reach .
It's especially chal lenging to make prosthetics for children since they’re in
constant state of growth . Rochester Institute of Technology scientist Dr. Jon
Schull stumbled upon a clever and affordable solution , provided online open
source templates to anyone anywhere in the world who has access to a 3D
printer and provide prosthetic hands for next to nothing. So he founded the e -
NABLE network which has massed thousand of volunteer makers providing
cheap but functional prosthetics for children in need.

Dr. Jon Schull : I thi nk we're currently pushing 5800 identified members in our
Google Plus community . We know that we’ve delivered about 800 hands
devices.

Mark Masselli: The simple limb designs have become more sophisticated as
recipients of the prosthetic devices provide feedback for designers to make more
efficient devices.

Dr. Jon Schull : We're still working on opposable thumbs . These things grip or
ungrip that’s all they do , but for kids it's huge and you know our hands don’t even
pretend to look like regular hands , they look like superhero Iron Man hands and
for that very reason they’re very popular with kids.

Mark Masselli: e - NABLE , a global collaborative network of open source designs
linking to makers with 3D printers to provide low cost prosthetic limbs to chil dren
and adults around the world , now that’s a bright idea.

Margaret Flinter: This is Conversations on Health Care , I’m Margaret Flinter.

Dr. Don Rucker – National Coordinator for Health IT at HHS

Mark Masselli: And I’m Mark Masselli , p eace and health.
Margaret Flinter: Conversations on Health Care , broadcas t from WESU at
Wesleyan University, streaming live at www.wesufm.org and brought to you by the
Community Health Center .