January 29, 2013
Innovation 101

By Zac Jiwa (@HITManZac), External Fellow for the Infrastructure of Medicaid & CHIP Project

in·no·va·tion noun \ˌi-nə-ˈvā-shən\

1: the introduction of something new

2: a new idea, method, or device : novelty

From <http://www.merriam-webster.com/dictionary/innovation>

Over the last several weeks, I have found myself challenged to be INNOVATIVE as an Innovation Fellow.  Sure, the job is challenging and figuring out the complex equation that is a MAGI eligibility determination shared service for state Medicaid agencies is not trivial, but that is not what I mean.  In this case I struggle with what it means to be innovative. 

First of all, INNOVATION is an overused buzzword, especially in government circles.  I do not mean to be negative or to take away from all of the good work being done by the  Innovation teams here in the Fed, but, if I had a dollar for every time that I heard a reference to innovation…well, you get where I am going.  It’s hip and cool to be seen as innovative, to “think outside the box”, to be “disruptive” or to be a “change agent”.  But what does it really mean?  And who decides?  And what if the obvious answer is notinnovative?

I suppose the reason that I struggle with it is, with regard to our project, the RIGHT solution, the OBVIOUS path does not seem all that innovative.  The best answer to our problem is staring us right in the face, has been exclaimed by many others before us and is not hard, not a new idea and is not novel as Merriam-Webster defines innovation.  Earlier this month, when meeting with Bryan (Sivak) to discuss our project, I made this observation to him.  That “I struggle with the natural solution to our equation because it is not really innovative.”  To which, he challenged my own definition (and Merriam-Webster’s for that matter), that it should be a “new” or “different” idea. 

Bryan’s rebuttal gave me a brief flashback of my early work in Louisiana.  In late 2010, I landed right off the train from Microsoft R&D and found myself in the midst of public sector sludge at Louisiana’s Department of Health and Hospitals.  It was my first job in government and I found myself very frustrated at the slow adoption of technology.  They were still using Windows XP on the desktop, most of the backend systems were ancient mainframes and introducing anything modern was met by a myriad of excuses.  I was used to working with tools that made it easy to communicate, collaborate and get things done and now I had to hunt people down and wait hours, sometimes days for an interaction that I was used to having over a quick IM conversation.  Compared to the “eat-your-own-dogfood” environment at Microsoft, I had gone from Disney World to Dicken’s World (for the reference http://www.dickensworld.co.uk/).  Soon I realized something very cool about this situation, though.  By making incremental advances that, to me were obvious and had marginal benefit, I was able to gain trust to make even more impactful changes.  I was sometimes seen as an innovator although I did not believe that what I was doing was all that innovative.  It was the opportunity to work in the private sector at one end of the technology curve and then step into the public sector at the other end of the curve that allowed me to be “innovative”.

Later, Chris (Lunt) and I were chatting further about the definition of innovation and he came up with another really great definition.   He defines innovation as “the ability to have one foot in one world while having the other foot in a different world and leveraging lessons learned across the divide.”  What a great observation!  We have seen examples of this many times over, whether it is crossing over from the consumer market to enterprise market, the automobile industry to the banking industry or the banking industry to healthcare, some of the greatest innovations of the last century can be resolved by this definition.

In the present case for me, I am able to bring my experience from a State Department of Health/Medicaid perspective and cross the divide to implementation at the Federal level.  Certainly it is a similar case for Chris who has spent his career in consumer internet technology.  The divide he is straddling is certainly wider than mine and that gives him a completely different lens in terms of innovation.  Where some of the challenges that we face may seem daunting or of questionable value by some of my colleagues at HHS, the answers are more obvious and unquestionable to me.  Whether that is innovative or not, I will let others decide, but it has certainly helped clarify my present dilemma.  I’m interested, How do you define INNOVATION?

And now for my quote of the day:

"Nothing is so embarrassing as watching someone do something that you said could not be done." - Sam Ewing

December 10, 2012
Jumping in Feet Last

By Zac Jiwa (@HITManZac), External Fellow for the Infrastructure of Medicaid & CHIP Project

Do you remember that movie Groundhog Day with Bill Murray? Well, I feel like I’m in it. But more about that in a minute. With this being my first blog post for the HHS Innovation Fellows Program, I feel the necessity to provide some background on me so that you can judge me appropriately. I’ll try to make it brief, but hopefully it will provide some context to my perspective on what I write today and in the future.

I have spent pretty much my entire career in Healthcare Information Technology. My first real job was working for a small startup that sold and supported physician practice management software in the late 90s. It just so happened that we were working with a number of physician practices that were super concerned about HIPAA and the management of their health records, so we ended up building an Electronic Health Record solution in-house. Building a solution from the ground up, working directly with impatient (and often unruly) physicians and healthcare workers at my young age was like the “Air Force training pilots for American Airlines” as my former boss used to say. It was trial by fire, for sure! This job is where I learned how screwed up our healthcare system is which motivated me to spend my career helping to fix it. I went on to work as a CIO for a pediatric multispecialty practice at Children’s Hospital of Austin, where I observed why and how providers and hospitals made decisions. From there to Motion Computing, a tablet pc vendor who was launching a tablet for the healthcare and hospital community and then on to Microsoft’s Health Solution Group where I focused on their Connected Health practice. (If you want more details you can visit my LinkedIn page at www.LinkedIn.com/in/zjiwa).

In the Summer of 2010, one of my then colleagues and mentors at Microsoft was appointed Secretary of Health for Louisiana. I was so excited for him but at the same time intrigued by why he would leave his cush job at Microsoft to go work for the public sector, let alone agree to move 2,000 miles from one of the most beautiful cities in the country (Seattle) to the sweltering swamplands of South Louisiana. Over a meal in August of that year, I finally got to ask him this question. The answer cut me so deeply and the job offer that followed led me to eventually make the same decision. Secretary Greenstein, who had come to know me and my passion toward leveraging health IT to improve health, convinced me that I was never going to change the world by running around selling software, and that if we were going to have a shot at doing so, there was not a better place in this country than in a state with some of the poorest health. So two years ago, I also left Microsoft to serve the State of Louisiana as the State’s first Health IT Coordinator and then the Department of Health’s first Chief Technology Officer.

Now back to Groundhog Day. When I took the job at the State of Louisiana, I somewhat expected to find inefficiencies and bureaucracy but I largely underestimated how bad it would be. The first few weeks of this new Fellowship with HHS, has me reminiscing about the “good ole days” as I find these same challenges multiplied by a factor of 100. I will not bore you with all the details of my experiences thus far, but suffice it to say that I am continually distracted from my specific focus in this fellowship to the mental exercise of figuring out how to solve the organizational inefficiencies that I come across daily at HHS. Chief among these in my experience is collaboration and communication. This is something that most of the Fellows have voiced as a challenge and are now working with CTO, Brian Syvak and others in the organization to hopefully champion resolution. I would boil the problem down to owning every tool in the book but using none of them consistently across agencies. This perpetuates something that I have said a lot in my career, that “IT is simultaneously the SOLUTION and the CAUSE for all things that do not work properly in an organization” - thus giving credence to the idea that “Healthcare is broken - we need IT to fix it!” Sorry I digress. I will say, though, what I am most impressed with at HHS is that they realize that there are problems and to that end the leadership is pretty creative in figuring out how to solve them. Having worked with Todd Park as the past CTO and now Bryan Sivak and team fueled with buzz topics like “Open Data”, “Data Liberation”, “Entrepreneurs in Residence”, “Innovation” and of course “Innovation Fellows”, you cannot ignore the effort that is being put in to the disruption of the status quo here. And when I refer to leadership support, it seems to go all the way to the top. During our (all Innovation Fellows) inaugural visit to the Humphrey Building in DC on November 13th, the welcoming committee consisted of Sec. Sebelius, Deputy Sec. Bill Corr, Assistant Sec. Ned Holland, Todd Park (US CTO), Bryan Sivak and a number of other agency leaders all very interested in the success of the Innovation programs here.

Before I conclude this post I guess should say something about the project that I was actually brought onboard to work on. You can read a full description of our project here, but to be concise, our goal is to enable at least 5 State Medicaid Agencies, who without our assistance would otherwise not be able, to determine Medicaid Eligibility based on the new Modified Adjusted Gross Income Calculations required by the Affordable Care Act. And I say “our” because HHS brought two Fellows onboard for this project, myself and Chris Lunt. Chris is a software developer from Mountain View, CA who has spent most of his career in consumer internet. You can read more about him in his blog post here, but I am super excited that they paired us up. I am learning a lot from him and I hope there is a thing or two that he is picking up from me. After just a few weeks together, we have been able to assemble a pretty thorough analysis of our options to see this project succeed. We gave our first presentation to our internal stakeholders last week and everyone seemed receptive to the way we are approaching things. Our challenge is complex in that we do not have ultimate control in the complete success - as, in our above goal, I used the word “enable”. What I mean by this is that I feel comfortable that together, we can “enable” but ultimately we rely on states (and their vendors in some cases) to implement. So by “enable”, I mean that we should be able to “lead the horse to water…”.

Our real challenge can be defined in our “Objective” statement: “To introduce a practical solution considerate of short timelines, complex procurement and budget constraints and state and federal politics while maintaining consistency and integrity of the eligibility determination rules.” Our biggest challenges thus far have been navigating the channels of information, weeding out the irrelevant and identifying those who can help us achieve our goals. This is not only internally at HHS or CMS (Centers for Medicare and Medicaid Services) but also stakeholders in states and vendor representatives who will need to provide input. The latter is where my background and experience will help, but also where our primary point of contact on the inside, our Internal Fellow, the incredible Jess Kahn, comes into play. Thank God for her as I think we would be lost. Jess so far has been very gracious in helping educate and navigate. That said, there is so much going on with CMS with everyone hunkered down determined to be ready for October 1st, 2013, that it can be difficult getting some folks attention. Right now, our single biggest challenge, and risk to success is getting our hands on the final rules for MAGI eligibility - we are hoping for some time this month. We can plan and build all day long but if we do not have these rules finalized in time, it will impede our progress and success. Everyone seems confident about meeting timelines, so I won’t stress for the time being.

One other thing that I should probably mention, which probably lands in the category of “challenges”, is that both Chris and I are telecommuting. Which means that we are working out of our home offices from afar, me in Baton Rouge, LA and he in Mountain View, CA. On one hand, this is a great situation as it allows us to avoid being bogged down in some of the onsite minutia. We use Skype to communicate and are able to be quite efficient externally. On the other hand, I have learned that there are times when you just need to hover outside someone’s office until they let you in so that you can get something done. HHS does not have a singular, consistent solution for IM, audio and video conferencing across agencies, so there’s not really a simple way to ask a “quick question” without setting up a conference call or playing phone tag. Additionally, the IT Department has CMS and HHS locked down like Ft. Knox so no holes in the Firewall for Skype. I’m not sure what is going on with all of that nonsense…I guess I’ll let you know when I find the room filled with gold bricks. Our current solution to internal coordination is to call Jess and have her run “errands” for us, but this is entirely inefficient. I am committed to being obnoxious about this pain point until someone takes notice. As they say, “the squeaky wheel gets the grease” although I have also heard that sometimes “the squeaky wheel gets replaced”.

Ok, I’ll wrap it up for now, but look forward to bringing more of my experiences to the HHS Innovation Fellows blog soon! And now, for my quote of the day:

M. A. Rosanoff: “Mr. Edison, please tell me what laboratory rules you want me to observe.” Edison: “There ain’t no rules around here. We’re trying to accomplish somep’n!” — Thomas Edison

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