High Stakes

Thinking Like a Fighter Pilot to Improve Transparency in Healthcare

Thinking Like a Fighter Pilot to Improve Transparency in Healthcare

In this turbulent industry, we’ve often said healthcare leaders are building a plane while they’re flying it.

It turns out, experience flying actual planes has given Ed Cantwell, CEO of the Nashville-based Center for Medical Interoperability (CMI), a 30,000-foot view of the twisted course towards healthcare transparency.

As a former fighter pilot, he’s leading an effort to help hospital and health system leaders develop a strategy to achieve transparency. His major focus now is to drive interoperability and data liquidity – which should enable information within the healthcare system to be available when and where it’s needed.

He recently shared his thinking on how the forces acting against transparency are like those in aviation:thrust, lift, weight and drag. He also explained why, at this point, leaders who need real change must stop admiring the problem and start addressing challenges that keep the proverbial airplane grounded.

Here’s our conversation.

Shelley DuBois: Let’s start with a broad question: How do you think about solving transparency problems in healthcare?

Ed Cantwell: I think that in healthcare, the transparency-issue algorithm is very similar to aeronautical engineering: Can thrust and lift overcome weight and drag?

I’m not sure I have ever heard healthcare transparency compared to aeronautical engineering.

Oh my God, does the analogy apply. Let’s start with thrust and lift. “Thrust” is forward motion powered by fuel. In healthcare, it’s the allocation of resources, financial or human, to develop and demand transparency. As a plane moves forward, lift is generated in proportion to the velocity created by thrust. So in our industry, “lift” would be a law, regulation, public outcry or tipping point.

Those forces must overcome weight and drag. “Drag” is a direct headwind that opposes thrust – it is the force that fights against you. An example of drag in opposition to healthcare data liquidity is an electronic medical record (EMR) system that exists in a silo and blocks the two-way exchange of patient data – it can be contractual, technical or financial. It’s fighting interoperability. Weight is just the weight of what is: the weight of budgets, human behavior, or sunk costs in proprietary systems.

Tell me more about weight in healthcare.

One of the most significant weights is our payor platform, plus the fact that, on a daily basis, healthcare CEOs don’t know the costs they’re going to eat because of the uninsured burden they must carry. The healthcare industry is not a normal free market because the revenue per a certain service is variable. And if the revenue remains a variable, how do you lock down a transparent price?

The pricing problem is so massive – how do you start to tackle it?

Transparency requires data liquidity. Data liquidity requires interoperability. Interoperability must be embraced by the market that wants transparency. Notice I said the market, not the hospital.

If the market isn’t the hospital, what is the market?

When I say market, it’s the care team, the person and the healthcare system. Payors, vendors, associations and lobbyists are all secondary. In this environment, you’re looking at a situation where maybe the care team and the patient want transparency, but the factory of healthcare hasn’t invested in the platforms to enable interoperability, which drives transparency.

You can actually segment the healthcare market into four battlefields. The first battlefield is you, personally. Do you have a personal longitudinal medical record?


Well then, you’re a soldier on that battlefield that’s not even fighting a war. You’re most citizens, who don’t have a clue where their medical information is, or how to use it to lead a healthier life.

The second battlefield is the traditional episode and transition of care. I call that the factory of healthcare. The third one is, once you go through the factory, how your information gets shared with another factory.

The fourth battlefield is a marketplace that has achieved data liquidity in every other market. The marketplace is poised to say, “I’m not going to tolerate it.” Consumers are used to Apple, Google, Amazon. You live in ultratransparency, in fact, to the chagrin of personal privacy.

Which battlefield is the most interesting one in terms of creating actual change in healthcare transparency?

The marketplace. It’s Apple and Amazon coming to the table. They’re going to do the data liquidity piece. They are going to address the four forces. And guess what they can bring? Thrust and lift. And guess why? Because you, personally, are their unit economic. All they have to do is capture you personally and use data liquidity to optimize healthcare around you as a person, not you as the patient of some hospital.

What they can’t do yet is provide the caregivers. It’s time for healthcare systems to embrace the same level of data liquidity found in every other aspect of your life and leverage it to deliver better outcomes at a sustainable price. Once that happens, the partnership between the healthcare market and the consumer will be incredible. It should be a partnership, not a fight.

I have a feeling some of these concepts might not land well among risk-averse healthcare CEOs.

I think you’re wrong, I think they’ll step up. It’s my job is to lead the charge. We’ve got to move past admiring the problem, and unless a handful of key leaders are going to stand up and address the root cause, we’re going to have this conversation 10 years from now, but it’s going to be worse.

You won’t find anybody on the planet stupid enough to argue against having transparency. But the conversation must go beyond admiring the problem.

How do you get CEOs on board to go beyond admiring the problem?

I tell them, ‘Are you going to be on the list of CEOs that go down in history as addressing the root causes that lead to the lack of transparency?’

Do they want to be on that list?

The CMI board members do. They’re relatively small in number, but they represent an extraordinary amount of procurement power. If they invest in systems that enable data liquidity and interoperability, they’ll get it.

What keeps you motivated to keep pushing for change in an industry that’s so resistant to it?

First, if we don’t address these challenges, the money we spend for the outcomes we get will financially cripple the U.S. economy. Every other industry has solved what we are trying to solve. I think that’s how I stay motivated.

Ninety percent of the time, I’m not acting as the persona of the Center for Medical Interoperability CEO, I’m Ed Cantwell, and I’m pissed. Be pissed off personally. They should never take away your personal passion about this, because the unit economic in healthcare is the person.


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