Cost reduction had never been Dr. Karen Rheuban’s overriding agenda. Her passion was ensuring that as many patients as possible, even in the most remote rural communities, got access to world-class care. We first met in 2006 when, as Secretary of Technology, I was touring the University of Virginia in Charlottesville. I dropped by her telemedicine clinic to learn more about her work in videoconferencing in health care, which was removing barriers by allowing patients and doctors to communicate face-to-face from different locations, but which—to her frustration—was not compensated under the current fee-for-service health care system.
Minutes prior to our brief meeting, Rheuban fielded a call that adjusted our agenda. A baby had been born with a heart defect, the severity of which the hospital in Lynchburg was ill-equipped to treat. Rheuban diverted from her planned pitch to attend to this more urgent matter, engaging with the staff on the other end of the telemedicine call, reviewing the relevant lab values and medical data, and rendering her decision. The child needed surgery, without delay, or he might not survive.
Her intervention, through this technology, saved a life. No pitch necessary. I got the message.
Following the PIF launch a few months later, I thought of Rheuban, and how to connect her critical work to our young initiative. Certainly we could do some good by bolstering her existing programs, which were barely surviving on grant funding. But we wouldn’t necessarily fulfill the PIF’s mission of generating measurable savings and efficiencies for the Commonwealth. We needed an economic rationale to act, and we identified such a trigger in some troubling statistics. While Virginia ranked in the upper echelon in many categories, such as wealth per capita and workplace quality, it was in the bottom half in national infant mortality rates. The leading cause of infant mortality, according to the Centers for Disease Control (CDC), was preterm birth—defined as delivery prior to the 37th week.10 According to the March of Dimes, Virginia graded a C in preterm birth rates, and some regions of the state were worse than that; the rural Shenandoah Valley had a rate more than twice the CDC target for the country. Rheuban had firsthand understanding of this problem, since many pregnant women from that part of the Commonwealth were delivering early at the University of Virginia Health System, often resulting in admissions to the Neonatal Intensive Care Unit. While we were blessed to have a state university that supported such a world-class NICU, these admissions were extremely costly to Medicaid—and thus, by extension, taxpayers. Each week that a child remained in the mother’s womb and avoided the NICU would save the state roughly $44,000.
We needed earlier intervention, so mothers at higher risk could take preventative measures to avoid early deliveries that strained the system—and in the worst case, led to infant death. In examination of the Shenandoah problem, Rheuban learned that many of the residents there lacked access to a “high-risk” OB/GYN specifically trained to treat those pregnancies that were most precarious. The typical political battle on this matter would likely come down to a fight over subsidies between those who deem health care a right and those who deem it a privilege. Those who deem it a right might argue that it was imperative to get a high-risk OB/GYN to set up shop in those communities; those who deem it a privilege might argue against the government essentially bankrolling the physician’s salary.
Rheuban was positioned to argue for an alternative path that could achieve comparable outcomes at a much lower cost. It wouldn’t require anyone moving anywhere, merely a modest investment in the telemedicine technology that she had championed, as well as fair compensation to the physician providing the virtual visit. Her hypothesis caught the attention of the PIF board, which approved a pilot study for $136,000. The early results were startling. Rheuban’s interventions achieved a roughly 25 percent reduction in preterm birth rates in rural localities over a three-year period, largely because patients missed fewer appointments, down from 11 to 4.4 percent. That was enough evidence to convince Governor McDonnell to sign a law requiring insurers to reimburse doctors for telemedicine services.
We didn’t need much more evidence that the PIF was serving its purpose, and yet the stories kept coming. In its first six years, and over the course of two gubernatorial administrations, one Democratic and one Republican, it would sponsor more than forty projects, and deploy more than $4 million, including savings that were reinvested into new enterprises. It would simplify the Medicaid application form for seniors. It would lower the permitting costs for mining companies. It would allow the tax department to scan millions of checks rather than the old way of getting them to the bank for deposit (via an expensive courier service), saving hundreds of thousands of dollars. It would save thousands more by switching the software in a K–12 school system from Microsoft to Google. It would give parents web access to quality rankings on preschools—since passing third-grade reading was a known precursor to later success, and earlier childhood education was critical for getting students ready to learn.
All told, the Productivity Investment Fund would deliver a 4-to-1 return on taxpayer investment, and advance key outcomes through innovation.11 The PIF had originated in a Democratic gubernatorial administration. But its ability to appeal to both sides of the political spectrum was again illustrated when Fred Malek—assistant to Republican Presidents Richard Nixon and George H. W. Bush—endorsed the fund in his report on reforming government, during McDonnell’s Republican gubernatorial administration.
Smaller? Bigger? Rather, a sterling example of smarter. Our work had left Virginia better prepared to confront the challenges of its future. I believed that it had done the same for me.
Chapter 4
Opening the Playbook
In late August 2008, I was in Colorado for the Democratic National Convention, not as an official delegate or sponsor but, rather, as a guest of Governor Kaine alongside many others from his cabinet. With Virginia in Presidential election play for the Democrats for the first time since 1964, and in light of Governor Kaine’s early endorsement of Illinois Senator Barack Obama, we were receiving the royal treatment—prime seats at everything from former Charlottesville bartender Dave Matthews’ rousing concert at Red Rocks to Obama’s electrifying acceptance speech at Invesco Field.
It was a festive time for the Virginia delegation, even independent of the perks. Just days earlier, our work had been flatteringly profiled in the New York Times Magazine, with an article heralding the Virginia Model as a living example of how Obama’s vision for the country might unfold. Obama’s economic adviser, Austan Goolsbee, noted that Virginia validated an innovation strategy that called for investments in human capital, R&D, and modern infrastructure to transform a once bottom-of-the-pack state into an economic powerhouse. Over the past 50 years, no other state had hiked its per capita income higher.1
While in Colorado, I met Julius Genachowski, Obama’s former Harvard Law classmate and among his most trusted advisers on technology matters, and who—at a forum held on the sidelines of the convention—quipped that Senator Obama had mandated that his staff insert a default paragraph about the importance of harnessing technology into every speech. This resonated with me. After all, the integration of technology was an important element of the Virginia Model, whether investing in electronic health records and rural broadband or increasing government transparency and efficiency. I would draw from the lessons of Virginia when Genachowski asked me to assist in outlining responsibilities of a prospective new position in the White House, Chief Technology Officer.
Obama won the state of Virginia, and won the White House. A couple of weeks after the election, Genachowski invited me to serve on the Technology, Innovation and Government Reform (TIGR) working group of the transition team. Organized under Genachowski’s leadership, TIGR would advise the President-elect on implementing his campaign vision about modernizing government. The TIGR team was, in itself, an innovation. Presidential transition teams are typically designed to operate as a mirror of the existing govern
ment, with a bevy of advisers specializing in each of the respective cabinet agencies and departments to prepare briefing memos for the incoming appointees of those particular agencies and departments. TIGR couldn’t be assigned to a specific cabinet agency or department, because that agency didn’t yet exist. Rather, it undertook an assessment of the technology and innovation opportunities across each of the respective agencies, in order to deliver a twenty-first century government that is more open and effective.
TIGR benefited from a running start, because its membership reflected two important constituencies. Many were key holdovers from the Clinton administration, those who had embraced the REGO, or Reinventing Government, model. They offered history and context. Others, including myself, were on the front lines of the most innovative technologies deployed in the private sector, and in the public sector at the state and local levels. We could readily identify the growing gap in the use of technology between the federal government and the outside world. Together, we began fleshing out a concrete agenda for the Obama administration to execute over its first 100 days, highlighting the need for a Presidential memorandum that would set the tone for a new operating culture in Washington. The memorandum would direct the Cabinet and agency heads to take actionable steps toward more transparency, participation, and collaboration—utilizing Internet-based technologies from cloud computing to mobile broadband to meet those aims.
While writing our recommendations, we recognized the unique challenges of the moment. The country was firmly in the grip of a financial crisis, the national dialogue consumed by the severe recession that the President-elect would be inheriting, a consequence of a precipitous crash in housing values and the spectacular failure of risky instruments on Wall Street. On January 8, 2009, at George Mason University, a dozen days prior to his inauguration, Obama made his most direct statements to date about the sober state of the economy, the likelihood of a grueling slog toward recovery, and the need for swift Congressional action to pass a stimulus package.2 He made the case for complementing short-term stimulus measures with investments that could create “a foundation for long-term economic growth.” Understanding the citizenry’s skepticism of the federal government following its mishandling of recent natural and man-made disasters and drawing upon his experience as the cosponsor with Republican Senator Tom Coburn of the 2006 Federal Funding Accountability and Transparency Act, Obama pledged that “every American will be able to hold Washington accountable for these decisions by going online to see how and where their taxpayer dollars are being spent.” He called for the construction of a Recovery.gov website, to be ready for launch on whatever day he signed a recovery bill into law.
We at TIGR got that assignment with a defined mission: build on the foundation of spending transparency that Obama-Coburn had established. Vivek Kundra, my former deputy in Virginia, took the lead. TIGR operated under the President’s embrace of the famous quote from Justice Louis Brandeis that “sunlight is the best disinfectant,” while fully understanding that critics—in the spirit of former Wisconsin Senator William Proxmire—might produce their own versions of his infamous Golden Fleece awards for wasteful spending. We also understood that we could take two routes to improve upon previous data transparency efforts.
We knew that one option was to publish the most granular possible data, enabling the public to trace the flow of funds from, for instance, the Department of Transportation all the way down to a small town’s stoplight. But we also knew the challenges of that ambition and that it couldn’t be accomplished anytime close to Day 1, since it would require the accessing of hundreds of individual databases, introducing the increased risk of data inaccuracies as well as limits on the timeliness of reporting. So we determined that, in the near term, we should aim to better organize the data that we could immediately access and confidently publish. That decision informed the path toward Recovery.gov, the launch of which—overseen by Kundra, now in the capacity of U.S. Chief Information Officer at the Office of Management and Budget—coincided with President Obama’s February 17 signing of the American Recovery and Reinvestment Act, and its $787 billion in stimulus.3 That site would include maps, charts, and graphics, giving taxpayers a better sense of where the government was spending all of that money. While specificity was limited initially, we would keep pushing until users were able to drill down further and determine how the Recovery Act impacted their neighborhood.4
Meanwhile, President Obama continued planting the markers of open government. On his first day in office, four weeks prior to the Recovery.gov launch, he implemented the TIGR team’s primary recommendation, penning a memorandum that not only called for an unprecedented level of transparency, participation, and collaboration but also defined the responsibilities for the Chief Technology Officer, a position that had yet to be filled. He directed that person to provide a new set of recommendations that would inform a more detailed Open Government directive that the President would issue to the government through his management arm, the Office of Management and Budget.
Now, who would be taking up that task? We, on the TIGR team, suspected it would be Julius Genachowski, though he would instead become the Chairman of the Federal Communications Commission. Meanwhile, I was in discussions with Health and Human Services to create and fill a similar position for that agency. That was, until I met with the head of Presidential Personnel on a Monday in April 2009. It quickly became apparent that the White House was focused on something else: vetting me for the still-vacant U.S. CTO position. For the next two days, my personal, career, and financial history underwent extensive review. That Saturday, in his weekly address, the President announced my appointment to a role in which I would “promote technological innovation to help achieve our most urgent priorities—from creating jobs and reducing health care costs to keeping our nation secure.”5
A few hours after that aired, I celebrated at my 15-year college reunion with my closest friends and our families. Well-wishers from the tech community, including the publisher, thought leader, and entrepreneur Tim O’Reilly posted blogs and comments endorsing my nomination. The O’Reilly post best outlined our opportunity to build “Government 2.0.”6 That catchphrase drew upon the premise that government could be a platform, not unlike Amazon, Google, and Facebook—one that went beyond providing generic services directly to its customers, the American people, but invited and enabled those citizens to cocreate, personalize, and perhaps improve its offerings.
Still, my work could not begin until I received Senate confirmation. That hearing was Tuesday, May 19, and it was uneventful, but for the pace of activity that followed.7 I was approved by the Committee on Wednesday and by the entire Senate by Thursday. On Friday, I was sworn in. This came at a time when Obama appointees were averaging more than two months for approval. I believed this had less to do with me than with the promise of the position—one that was intended to make government better not bigger, through the application of technology, data, and innovation.
My confirmation coincided with the launch of two major open government initiatives, following months of testing and development. One was Data.gov, a centralized portal available to anyone without any burdensome cost or intellectual property constraints. For this project, Kundra leaned heavily on the experience he gathered before joining the administration, when he was Washington, D.C.’s Chief Technology Officer. For the District’s government, he had created a “data catalog,” giving its taxpayers, in Kundra’s view, “access to what was already theirs”; that meant everything from Metro bus and train schedules to school performance assessments to the credit card transactions of government officials to the addresses of companies that won government contracts. Further, that access was offered in a format that made it simple for software developers to create applications that would help citizens in their daily lives. One application, Stumble Safely, used crime data to offer suggestions about the safest bars to frequent; others gave users the nearest police stations, plac
es of worship, and post offices.8 Kundra’s overall vision was loosely based on the ancient Greek concept of the agora, in which people congregated at a public square to socialize, conduct commerce, and petition their government. Only now, he was giving them the same opportunity through a digital public square, one that didn’t require venturing anywhere other than to a website on a personal computer or mobile device, in the privacy and comfort of one’s surroundings.
Kundra was convinced that by opening other data sets, on everything from health care to the environment to education to procurement, the American people would not only feel empowered as watchdogs, but would be inspired to create a fresh portfolio of services that blurred lines between the public and private sector, to the benefit of the broader economy or simply to the benefit of their fellow citizens. For instance, the Consumer Protection and Safety Commission had been compiling data on toys and other products used by children, out of the public’s sight. Once that data was set free, creative thinkers could step in and utilize it in ways that few had considered, such as the creation of an application that allowed a consumer to scan a crib’s bar code in a store and learn if the model had ever been recalled. And that was just scratching the surface of the potential of opening government data, as we will explore later in this book.
The second major initiative launching was meant to stimulate civic participation. The deputy Chief Technology Officer in the White House, Dr. Beth Noveck, conceived a three-part Open Government Dialogue, one that began with an online blank sheet, welcoming any ideas from the public that fit into one or more of the three categories from the President’s memorandum—transparency, participation, and collaboration. The public could then vote ideas up or down to provide a raw measure of popularity. This was a form of crowdsourcing, which entails “obtaining needed services, ideas, or content by soliciting contributions from a large group of people and especially from the online community rather than from traditional employees or suppliers.”9
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