The Robert Wood Johnson Foundation in Princeton is dedicated to considering new approaches and ways of thinking to help build a Culture of Health in the United States. RWJF’s entrepreneur in residence (EIR) role is one of many ways it seeks out these diverse perspectives. Bryan Sivak, former chief technology officer for the U.S. Department of Health and Human Services, recently began as RWJF’s new EIR.
Coming from a long line of doctors, including his father, grandfather, and uncle, Sivak considered going to medical school. But because he had become interested in computers as a child in Connecticut when his father brought home an early model IBM PC in the 1980s, Sivak studied computer science at the University of Chicago, Class of 1997. After participating in a start-up venture, Sivak was recruited to serve as chief innovation/chief technology officer for Washington, D.C., in 2009. He later became CIO for the State of Maryland and then CTO for the U.S. Department of Health and Human Services.
Sivak recently discussed his perspectives on entrepreneurship, cross-sector collaboration, and making data actionable with Lori Melichar, a labor economist and director at RWJF who has a Ph.D. in economics from the University of Maryland. Excerpts are below:
Lori Melichar: What lessons from your work at Health and Human Services and as Maryland’s first chief innovation officer do you hope to bring to RWJF?
Bryan Sivak: Many people equate “innovation” with “technology,” but I think that’s misleading. Technology is rarely the solution. More often, it’s a catalyst, enabler, or accelerant for the thing that actually does solve problems, which is behavior and culture change. In some respects, tech is easy while behavior change is very hard, but it is doable.
My work is all about enabling change in large, complex ecosystems, and if you think about what the Foundation is trying to achieve with its mission of building a Culture of Health, it’s exactly that. Through my work in government, I’ve found some straightforward techniques to approaching culture change in systematic ways. The first step is to identify the problems you are trying to solve and determine what would constitute success.
Once you know the problems, you can identify a set of solutions that could move the needle, and construct initiatives that are designed to accomplish this in a rapid, iterative fashion. Finally, you have to find your early adopters — the people who are clamoring to try new things — and help them find success.
Melichar: We are seeking new perspectives on persistent and perplexing health problems. How will you push us to see our work anew?
Sivak: I believe strongly in the idea of “serendipitous collisions” (to quote Tony Hsieh of Zappos). The theory is simple: The more heterogeneity in a given population who are focused on working on the same macro issue, the more likely there are to be breakthroughs.
My background is fairly diverse, ranging from the Silicon Valley-based world of enterprise software, to work across Europe and Asia, to stints in local, state, and federal government here in the U.S. I’ve collaborated with a number of people and organizations whose ideas and experiences will be an important part of the pursuit of a Culture of Health, but who might not have been obvious candidates to include in the conversation.
In terms of helping push the foundation, one of my favorite tools is one of the simplest: asking, “Why?” Too often, people in organizations become comfortable with existing processes and procedures and don’t challenge themselves to come up with something new. Asking “why” a few times in a row can often reveal some interesting details that illuminate where experimentation is possible and better outcomes could result.
Melichar: What is your definition of an entrepreneur? How will you help us at RWJF to act more like entrepreneurs?
Sivak: To me, an entrepreneur is someone who can see opportunities in white spaces between existing solutions, or recognize areas where novel combinations of existing components can result in something brand new, and then execute on the delivery of those ideas.
I don’t believe that there is any one way of “acting like an entrepreneur” — there are many different elements that require different skill sets and ways of thinking. I am new to the Foundation, but from what I can see so far, I would suggest that there are several things to consider.
First, the organization could embrace intelligent risk-taking by defining very specific areas of interest and soliciting novel ideas in those categories whose success is far from guaranteed.
Second, the Foundation could encourage data-generating rapid experimentation and proto-typing, in addition to constructing primarily long-term efforts.
Finally, consider setting the default to action and delivery — actually getting things done — and focus on the end user of any intervention.
Melichar: Another integral part to building a Culture of Health is encouraging cross-sector and inter-professional collaboration to spark new ideas and discover novel approaches to solving problems. Where do you see the greatest opportunity to do so?
Sivak: There is health value in nearly every area of modern life. Transportation, food, housing, education, telecommunications, and more all contribute to health and well-being, and as such, there is a “health value” that can be calculated for nearly every intervention across sectors. Too often these sectors don’t connect to consider how each area can positively — or negatively — influence the other.
One of the best opportunities here is to directly connect the work of the Foundation to hyper-local activities in cities and towns across America. This runs the gamut from policy decisions to specific targeted interventions.
For example, what if transportation and city planners had the tools to actively consider the health of their population in designing public transit routes and public space? What if zoning laws could be updated to factor in the health of the population with respect to the built environment? All of these ideas can be explored through on-the-ground experiments through partnerships with local jurisdictions and organizations.
Melichar: How would you go about demonstrating the value of civic improvements?
Sivak: There are some civic improvements that lend themselves to an analysis of health impact, and bike lanes are a good example. From a cardiovascular perspective, it’s clearly healthier behavior to ride a bike instead of taking a car, taxi, or even public transportation. At the same time, there are some entries on the opposite side of the ledger, including increased rates of accidents (although good bike lane design can reduce this).
Point being, the health impact can be quantified and measured. There are also civic improvements that are much harder to measure in terms of health impact. For example, look at New York City’s work to create “parklets” — turning space that used to be reserved for cars into public space for pedestrians to gather.
It’s very difficult to measure the “health value” of these spaces, but I would argue that it might be less about individual health and more about community health.
Melichar: You would engage a data scientist to understand how individuals use an innovation to improve their own health. I would engage an economist to produce generalizable results that can help us predict how this innovation might impact other cities. Who would have the right approach?
Sivak: We’re both right. There’s an art to interpreting and visualizing data that many data scientists are able to offer that standard economics training doesn’t necessarily include. But you can easily imagine how a macroeconomist might leverage the analyses provided by data scientists to make predictions on a broader scale. As you get less granular, it gets harder to make predictions with confidence, since there are so many interconnected systems at play. Maybe this is one reason why health interventions that seem to work in specific communities fail when exported to others?
Melichar: You have told me that you see little distinction between what those seeking to build civic engagement and those seeking to build a Culture of Health are trying to accomplish. Can you say more about that?
Sivak: Health in general and a Culture of Health in particular are completely intertwined with the notion of an engaged citizenry. There are many levels to citizen engagement, one being a focus on things like rules and regulations, government interactions, and the like, but there are less commonly thought of areas such as how communities interact with each other and internally. As an interesting thought experiment, look at the issues that have been in the forefront of the news recently around interactions between primarily black communities and local police.
I have often wondered if there was a way to generate more empathy in these communities that could help alleviate or even resolve some of the problems we see today. One can imagine experiments — some driven by technology and others very much based in real life — which could help people see the world through another person’s eyes. To me, this is a form of civic engagement that very much results in a Culture of Health.
Melichar: One of the Foundation’s core tactics to building a Culture of Health is to use data to drive action. What are the barriers to doing this and how might we address them?
Sivak: There are many barriers, including the availability, complexity, privacy, and security of data. Some of the challenges have to do with a deeper understanding of the regulatory environment, such as HIPAA. Some barriers are due to business practices. A significant challenge is using data in a way that respects the privacy of the individual. These are all significant challenges but all are possible to overcome.
Some of the best examples of making data actionable lie in the spaces where it pays to do so. For example, health care providers who are accepting risk in value-based arrangements have found detailed, near real-time encounter data invaluable to improving the health of their patient population — we see this in many of the institutions that are encouraged through financial incentives to prevent unnecessary readmissions.
Some providers are also using aggregated data to identify lower-cost procedures with better outcomes. “Population health management” and “care coordination” have become the buzzwords of the day — but they require good data to work well.
Melichar: You could apply your tech skills to any domain. What drives you to remain focused on health?
Sivak: My passion is working on things that matter. Health and health care in the U.S. is at a serious crossroads — we spend more on health care in the U.S. than the next 10 countries combined and our outcomes rank us near the bottom of the pack. As a result, there is a tremendous opportunity to challenge the status quo, ask some hard questions, and build solutions that will chart a new course in our journey toward a Culture of Health.