Innovative State

by Aneesh Chopra

  “Given a chance, there’s a voice that can be heard,” Garcia said. “I think this is an opportunity for somebody like me, who nobody would consider, to have a chance. Just give them the right criteria. We do have the resources. Sometimes we get caught up in the whole political thing, but it doesn’t have to be like that. Let’s not wait 10 years. Let’s make a change.”

  Dr. Farzad Mostashari wasn’t willing to wait even 10 weeks before making his mark on the situation he inherited in 2011, as Deputy Director of the Office of the National Coordinator (ONC) for Health IT in the Department of Health and Human Services (HHS). The ONC had originated in response to President Bush’s bold statement in 2004 that every American would have access to a personal health record by 2014. Yet, due in part to a modest annual budget of $60 million, the agency’s achievements trailed that pace, with only 25 percent of eligible physicians and 15 percent of acute care hospitals adopting electronic health records as of 2010. Recall, as introduced in Chapter 6, that the agency had received a one-time $2 billion cash injection in 2009 as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act in the stimulus bill, to be spent over the next few years on the creation of a nationwide interoperable health information network.17 Then, a year later, the Patient Protection and Affordable Care Act further validated the HITECH Act by recognizing health IT as a critical enabler in health care delivery reform.

  Even with all those enabling ingredients in place, Dr. Mostashari recognized that the agency needed to evolve from its legacy culture. That had emphasized process, largely measuring its success based on the amount of grants given to states, rather than on what the money actually produced. “We had to turn that around to say, no, no, no, if the country fails, we have failed,” he said. “And it’s not enough to have done things with the right form, we care about the outcomes. We had to give people the courage to do things differently. Our identity at ONC was to become government entrepreneurs, and that’s everybody from our grant management staff to our project officers. The core is, how can we see tomorrow as better than today? We’re not going to keep doing things the way we’ve been doing them, and we’re going to look for opportunities for those disruptive innovations.”

  That meant turning to cloud technologies to speedily support the expansion of their mission; putting a premium on accountability; and setting seemingly impossible goals, because in Dr. Mostashari’s mind, “When you know it is an impossible goal, then risk taking becomes less risky.” That also meant turning to different procedures, in concert with procurement, in order to achieve existing and ongoing objectives.

  “You can either do a grant and you have no control, or you can do contracts, and then you’re paying through the nose, and there’s no incentive for them to really deliver cheaper or better, and you only get one shot at it—you do the wrong selection of who you are going to work with, you’re screwed,” Dr. Mostashari said. “Prizes and awards seemed like a great way to get out of that box of the typical government procurement options.”

  Nor would it be a one-time trick. ONC would become the first agency to fully operationalize the prize authority that, a few months earlier, had been granted by the reauthorization of the America COMPETES Act. Mostashari’s agenda was twofold: speedily surface a series of solutions while creating a culture of community problem solving. His first major foray, the Investing in Innovations (i2) Initiative, included the allocation of nearly $5 million to fund prize purses, and was supplemented by administrative support from private sources.18 As a primary partner, Dr. Mostashari wisely chose Health 2.0 LLC, an event planner that, since 2007, has been hosting conferences, code-a-thons, and challenges in the consumer health space. In October 2009, I addressed that organization’s annual conference and was overwhelmed by the size and passion of the audience: more than 500 developers, entrepreneurs, and health care professionals who had also brought their own ideas for lowering costs while improving quality through better wellness and prevention services. Those ideas, unlimited in terms of imagination, were limited in their financial potential by the predominant payment system in health care: fee for service.

  As of this writing, ONC has sponsored more than 25 challenges tied to the use of information technology, with goals as varied as ulcer prevention, quality of life improvement for cancer survivors, and better reporting of medical errors. One representative example was the One in a Million Hearts Challenge, designed to complement HHS’s broader Million Hearts campaign to prevent one million heart attacks and strokes within five years.19 The winners were named in March 2012, with THUMPr taking the $50,000 grand prize—it was a web-based application through which users entered personal health profiles, then received unique recommendations for specific, actionable steps related to the ABCS (Aspirin, Blood Pressure, Cholesterol, Smoking Cessation) that would represent a healthy heart plan. The $20,000 runner-up, mHealthCoach, was submitted by South Asian immigrant Aamer Ghaffar.20 It was built on top of his startup’s $25,000 first prize winner in the Walgreens Health Guide Challenge, which took HHS data feeds, compiling the 20 most common questions related to cardiovascular patients, and providing a search engine for simple use by health guides Walgreens was employing to assist customers. For the HHS challenge, mHealthCoach leveraged social media sites Twitter and YouTube to supplement education with organization and enjoyment, allowing the user to integrate doctor’s appointments and gym sessions with a Yahoo or Google calendar, play games that demonstrate what happens to blood as it encounters exercise versus cigarettes, or even use maps to invite friends to fitness groups at nearby parks.

  Ghaffar spoke of enjoying a sizable publicity and credibility boost from each challenge but reaping the greater overall reward from the public sector competition, even though the prize was $5,000 less. That’s because the two-way dialogue with HHS and ONC—as compared to the private sector sponsors—continued after the conclusion of that challenge. “They recognize that the next hurdle of innovation is the lack of deployment or feasibility trials,” Ghaffar said, explaining that the availability of such testing environments—the sort government has the power and impetus to provide—can make the difference for small enterprises limited in their financial resources and connections to power.

  Later, Ghaffer would compete for other challenges, finishing second in an important one in the private sector, the Patient Engagement Blue Button Challenge sponsored by the Advisory Board Company.21 That was the latest in a long line of competitions related to the still-developing Blue Button movement, as private and public sponsors attempted to make consumers, even the technology-averse, more comfortable serving as the central hubs for their own health care information, and more responsible for sharing it. The Advisory Board stepped up to the sponsorship challenge based on the belief that the market was best suited to create simpler, more accessible, and appealing products—ones that would compel patients to make the downloadable Blue Button file a core component of their health care routines.

  On the private sector side, the 2010 Health 2.0 Blue Button Developer Challenge produced a rather impressive winner. Michael Jackson (no relation to the international celebrity) didn’t have the money for college while growing up in Baltimore. So he worked as a power plant operator and enlisted as a Coast Guard reservist to earn money for college; then he earned an MBA and took several technology jobs before ultimately joining Adobe, the gold standard of graphic design software companies, in March 2010.22 The challenge, sponsored by the Markle and Robert Wood Johnson Foundations, gave Jackson a chance to, as he put it, “prove myself to Adobe, and prove what Adobe could do for the industry.” His cross-functional team worked for 60 days to finish a prototype, creatively converting the Blue Button’s raw dump of text into a more attractive and useful package, including features that allow the user to easily, visually identify trends or spikes in health measures such as blood sugar levels. After winning, Jackson got a shout-out from the CEO, Shantanu Narayen, at the company’s governm
ent conference and, even better, a promotion.

  In search of a similarly uplifting outcome, Dr. Mostashari teamed with Health 2.0 in 2011 to present the Blue Button Mash Up Challenge, calling for competitors to create a broadly available application that blended Blue Button data with other data sources.23 Humetrix, a software innovator with a 15-year history, won the contest with its submission iBlueButton, which integrated eight different federal government data sources, all while taking the complicated coding and unwieldly length out of up to three years of Medicare claims history. The result? After logging on to the application, a patient—or the patient’s authorized caregiver—can tap a blue button to quickly download his or her Medicare record, and scroll down an organized, detailed list of diagnoses, medications, prescribing doctors (with contact information), allergies, hospital visits and stays, procedures, lab work, and even family history. With an extra click, the patient can receive additional contextual information, such as the potential side effects of current or considered medications, or preventative services, all drawn from those public databases. Then the patient can “push” his or her medical record to a provider who has downloaded a related app on a mobile device. After the medical professional accepts the transfer, they can review the record together, one bound to be more accurate than what the patient would recall from memory. And they can make more informed, collaborative decisions.

  The Humetrix story, and the dozens of others that surfaced on account of Dr. Mostashari’s emphasis on prizes, further inspired him to institutionalize the approach, so that it would be sustained long after his tenure. He did so through the Federal Health Information Technology Strategic Plan, published in September 2011.

  The prize tool for government innovators is gathering momentum, especially in the area of IT software development, which has been riddled with cost overruns. As noted earlier, Veterans Affairs had embodied the losing culture of government IT acquisition, with the nasty habit of contracting first—based on the fancy prose of some written proposal—without viewing a working prototype. Among the most egregious examples: a nearly decade-long, ultimately doomed, $127 million effort to help veterans schedule appointments with doctors, hospitals, and nursing care facilities online.

  An audit report from The Government Accountability Office stated the situation plainly in 2011: “Unable to implement any of the planned capabilities. The application software project was hindered by weaknesses in several key management disciplines, including acquisition planning, requirements analysis, testing, progress reporting, risk management, and oversight.”

  By then, Roger Baker—after assuming the role of VA CIO in 2009—had already overseen a thorough review of that and two dozen other underperforming major IT projects. He had suspended the scheduling project to stop the bleed, but knew that veterans still needed the service. With an assist from VA CTO Peter Levin, Baker launched the VA Medical Scheduling Contest—which we mentioned earlier. The challenge, with a total $3 million prize purse, fit snugly into Dwayne Spradlin’s characterization of ideal competition construction: a clearly defined problem with a logical connection to existing technologies that could be deployed at relatively low cost, and one that may not have surfaced through traditional models of government procurement.

  Across the country, millions of well-meaning public servants, feeling restrained by bureaucracy, limited in authority, and shackled by shrinking budgets, can still lead in the prize movement. Take Tom Baden. As a teenager and into his 20s, he was a singer and strummer in rock bands, playing Black Sabbath and Led Zeppelin covers and even sharing a stage with Yanni.24 Three decades later, as the Chief Information Officer at the Department of Human Services in Minnesota, he sought to make some noise inside state government by modernizing its historically siloed data systems.

  After learning of the White House Office of Management and Budget’s $45 million Partnership Fund for Program Integrity Innovation, a fund to support innovations that reduced waste, fraud, and abuse, Baden began to assemble a coalition of states that shared a common interest in solving these problems, ultimately securing the support of Louisiana, Oregon, and Utah.25 He would scope a small enough project with sufficient impact to move forward—­standardizing the registration process for doctors and hospitals when qualifying for Medicaid services. This targets the first of three stages during which states can intervene to thwart fake providers who cost them an estimated $11 billion in improper payments each year (the other stages being just before the claim is paid and after a claim is paid and deemed fraudulent).26 After winning the grant funding, Baden still needed to coordinate the project across the states, and he found a crowdsourcing vehicle called TopCoder—a highly competitive community for software development and digital creation, and one that had an existing agreement with a federal government “center of excellence” on prizes based at NASA. “What that did was take the complication out, which really accelerated the whole process,” Baden said.

  Working with the Centers for Medicare & Medicaid Services (CMS) and TopCoder, and facing significant skepticism, Baden’s team set the objective for the project: the creation of a screening tool to run background checks as well as identity, licensing, and financial verifications on newly enrolled providers. It followed the TopCoder formula of breaking down the project into smaller incremental parts, in this case 132 of them starting with conceptualization, with a prize for each piece ranging from $500 to $5,000 and “bug hunts” to reward hole pokers with small prizes to, as Baden put it, “Keep you honest every step of the way and drive up the quality of the product.”

  Through his commonsense approach, Baden drove up the quality of government without doing the same to the quantity of dollars—as of this writing, his project is still on course to successful completion.

  “The thing I like about TopCoder is that you only pay for the products that you like,” Baden said. “If you run a contest and there’s no winners, then you’re not paying anybody.”

  While it is natural for prize sponsors of all stripes to welcome the way these crowdsourcing models keep costs down, by compensating only a select, successful number of participants, this model is not necessarily a favorite of all professional societies.27 For instance, the American Institute of Graphic Arts (AIGA) has argued that such speculative work can devalue the design process, specifically the importance of feedback and experimentation to produce quality product; and that it can devalue the designers, diminishing the true economic value of their work.28 Designers have even created websites, such as nospec.com, to educate the public about the perils of spec work and to discourage their colleagues from performing it. And, in June 2011, more than 1,200 people signed a petition objecting to the Department of Interior’s $1,750 competition on crowdspring.com for a new logo for placement on clothing, one that complemented—but did not replace—the department’s existing seal.29

  While recognizing people’s right to reasonably disagree about the methods through which prize competitions are administered, and even to choose not to participate in this process, I believe there will always be a pool of talent motivated more by the mission than the reward. Government is tapping into that spirit, by broadening the range of competition topics—beyond its larger budgetary responsibilities such as defense and health care—to include those intended to foster equality, justice, and social welfare. That’s precisely how members of President Obama’s cabinet have utilized competitions to address key, often-unfunded priorities—expanding government scope without an equivalent, unwanted increase in size and cost.

  Start with equality. Hilda Solis, the Labor Secretary, took inspiration for her open innovation challenge from the 2012 State of the Union, in which President Obama declared that to create “an economy built to last,” America needed to “encourage the talent and ingenuity of every person in this country. That means women should earn equal pay for equal work.”30 He had attempted to address this issue with the first bill that he signed in 2009, the Lilly
Ledbetter Fair Pay Act, which allowed for a longer time horizon for suing retroactively for pay discrimination. A follow-through attempt, the Paycheck Fairness Act, a preventative step designed to protect employees who share salary information at work from retaliation by an employer, died in Congress.

  Solis assembled public and private salary data from sources including the Bureau of Labor Statistics and Salary.com, as well as cases brought through the Equal Employment Opportunity Commission (EEOC) for the purposes of supporting her Equal Pay Apps Challenge.31 She also convinced Professor Linda Babcock at ­Carnegie Mellon University to share her negotiating tips for others to incorporate into new tools. A team of graduate students at Carnegie Mellon’s Heinz College, led by Rachel Koch, won one of the grand prizes with the Close The Wage Gap app, which offered more personalized advice, in an application that included a negotiation cheat sheet for women. Laquitta Martell-DeMarchant was an especially inspirational grand-prize winner. Her childhood had been shaped by watching her two grandmothers raise families without husbands, a hardship that forced their children to work in the cotton fields of Louisiana to raise extra money. She came to believe that if more women could achieve equal pay, it would eliminate some of the burden. Her iPhone- and iPad-accessible application, Aequitas, includes the ability to compare compensation by ethnicity, and she has used the prize perks—including a scholarship toward an eight-week immersive coding skills training program—to build her company, FuzionApps. She is even planning a Spanish-language version. The President invited Koch and Martell-DeMarchant to the White House in June 2013, to commemorate the 50th anniversary of the Equal Pay Act, explaining his administration’s desire to “help workers get the information they need to figure out if they’re underpaid. And thanks to innovators like Rachel and Laquitta, who are up here, we can now say, ‘There’s an app for that.’”