On February 1, 2014, the AMIA iHealth2014 meeting convened a panel of the four former ONC Directors. Doug Peddicord was the moderator. The participants were David Brailer, Rob Kolodner, David Blumethal, and Farzad Mostashari.
The conversation was demonstrated just how much the vision for technology-supported care transformation has been consistent through over a decade and just how much each phase of our national journey requires different leaders, different messages, and different approaches.
I attempted to record the dialogue as carefully as I could. Since this was very much ad hoc and has not been reviewed by any of the participants, one should not attribute my comments to them. Any errors or misinterpretations are my own. I will try to revise this as any misrepresentations are brought to my attention.
The initial questions were raised by the moderator, Dr. Peddicord.
Advice & Reflections
Q: What advice would you give Karen DeSalvo, the new Director of ONC?
Brailer: I only did two things right. First, I asked Rob to replace me. Second, I asked David Blumenthal to engage. My advice to Karen is to "shoot big" and to not get focused only on small tasks but to look at the broader spectrum of health care IT as it enables a high performance health care system. She should lay out a broad agenda that transcends presidents and resets the health IT community for some "very big climbs" that we should focus on.
Kolodner: The "role changes as progress occurs." Challenges and resources change. What stage are we in? What need to happen? We have a lot of resources out there. They are not yet the right resources and technologies. There has to be a disruption of technologies. The [current technologies] cannot [yet] support a learning healthcare system. The technologies have to focus on the general health. Recognizing we operate in our self-interest, the role of ONC is to help balance forces and neutralize them when they slow down progress. How does ONC help foster this process? What is the role of government an policy? What is too important to have proprietary IT? We did this in a small way with SNOMED and a few other things, but we need to make more offerings more widely available, but which ones? We need to focus competition on adding value.
Blumenthal: Only the ONC is the spokesperson for "creating a space" for the health information technology agenda in the context of health care reform. It is a matter of "advocating the agenda; only the National Coordinator can do that." This starts by working within the government. One must make this argument to make "time and space" to get the policies implemented. Second, the ONC Coordinator can translate this agenda into the policy agenda. Figuring out the politics and policy "will tolerate' and making sure that policies "pushes it a little beyond what anyone thinks they can do." Finally, on must be open and transparent. The Office must "create a sense that this office is open, transparent, and listening."
Mostashari: She should relax. She doesn't have the toughest job - "not following David Blumenthal." The challenge is to link the technology agenda with the health care advantage. ONC must use the government as a platform and leverage the potential there to change. The culture within ONC is also important. One must retain the culture of entrepreneurship. "My one advice to her is to be yourself."
Q: Did you wish you had more power. If you had more, what would you have done with it?
Mostashari: It's not an issue of authority and power. "The smartest people don't work for you." What you need is "legitimacy, credibility, and influence." There is technology credibility as well.
Bliumenthal: Cited recent interviews of the President and that authority comes from persuasion. "The National Coordinator leads by persuasion in a much smaller terrain." One must understand where the technology is "on the ground" and to reconcile this reality with a "vision of progress." We had the authority to set standards, but one could not necessarily assure compliance. We could set incentives, but without buy-in, it wouldn't work very well. "The job…is one of persuasion and example setting."
Koloder: "The title is coordinating, not commanding." It is an "organic process" that isn't linear. You don't get your movement early. Sometimes the encouragement and enthusiasm lie "below the surface" and one has to be realize how progress happens. One has to be "somewhat delusional" but realistic that things don't happen as quickly as one wants. But each of us contributed to a "foundation." "I would have liked to have a few million HITECH dollars…but that wasn't the right thing. We needed time [first] to get the discussion started." He used standards as an example and said "it does beyond the standards now."
Brailer: I had "absolutely no power….no authority…no money." But in drafting the [GW Bush] State of the Union and Executive Order..the original term was "advisor" but changed to "coordinator." There were many of those and there was a convention. "We had no funding….Janet Marchibroda remembers that." He said that the original framework had not received government clearance." So he put Secretary Thompson's name not the cover and that made things happen. His fear is that the National Coordinator will have real power. "I live in the fear of it [ONC power] in the future." But he hasn't seen that. And as along as "coordinators come from industry," the prospects are good.
Q: You served at different times with different budgets, mandates, [etc]. If you had to switch your time of service with one of your colleagues, which one, and how would that have been interesting for you?
Kolodner: "I would have been number three [Blumenthal]." "I think that having the opportunity to guide the resources [aligned] with a major move towards health reform would have been an opportunity….I would have loved to have given it a shot."
Blumenthal: "I can say that I worked for the President during his campaign….but [HIT] was not my life's mission." "In retrospect, I wouldn't switch…but if I had to, it would have been with my good friend Farzad." David Brailer was a leader who encountered "huge resistance" and "we owe him a good deal of debt." Speaking of Farzad, he said that he had the job of "making it happen…and saved me on many occasions."
Mostashari: "I'll be a little revealing. I thought I wanted David [Blumenthal's] job but, "boy did they make the right decision."
Brailer: There were two alternative realities that I am desperately happy they didn't happen. A second
option was to "dangle off of…the Office of the President." The other was like "CMMI" and "being with CMS." The latter would have would have led to them "being killed." A major challenge was to engage CMS.
Blumenthal: The White House has little ability to make things happen. CMS has challenge with being entrepreneurial because of the major daily challenges they face.
Mostashari: "The one place that is limiting is in the technology part." The role is "clearly evolving into being the one person who is involved with all of the flows of information in in the healthcare system…its life cycle…how it is protected…how it is used." There has to be "someone who has to think of all of the data flows."
Brailer: He was initially opposed to inclusion of the Federal Health Information Architecure into his mandate, but learned it gave ONC the ability to get into the architectures and inside of the federal Agencies.
Kolodner: As a worker within the VA, he saw the operation for collaboration of his agency with HHS. This really had not happened.
Questions from the audience
Dr. Willa Drummond (U of Florida): I was at the first [ONC] meeting. But in 2004 on the wall of my cubicle of a clipping aiming 10 years into the future suggesting that the system would be completely built. I am now standing here 10 years down the road and I am amazed that the system is "75 percent built." Thank you.
Brailer: I was the "sweat equity guy,"and David was the "private equity guy" who raised [government] capital.
Kolodner: I had Brailer's promises and vision but had "no cash" as a government career person.
Mostashari: I remember David Brailer speaking. at the time 0.6% of prescriptions were transmitted electronically. In terms of hospital adoption, we just got data that MU hospitals account for 96% of discharges. I give the biggest credit to "the community as a whole. This is and continues to be a role of optimizing it….it hasn't been easy."
Blumenthal: David Brailer was generous in giving me credit for raising the money. HITECH was an unpredictable and tortuous act. It could not have happened without the great recession and the creation of the stimulus legislation. He spoke of the networks of relationships that led to the legislation. But "this was going to happen eventually….having medicine [still in the paper issue
ONC and other Federal Agencies
Mark LaFlemme (Tampa): When the announcement came out many organizations were in a relatively dismal state. They didn't have high speed networks and technology sophistication. And many still do not have this good fortune. "How much influence does the present NC have in influencing [the private sector]"?
Kolodner: The ONC has other agencies to draw upon. Referring to the CommonWell Health Alliance , he said that they could have joined government efforts [ NHIN & Federal Health Information Architecture ]. With Medicare and Medicaid, there is a lot of influence there.
Mostashari: Payment is changing so that there is an incentive for sharing information and coordinating. CMS is using its influence. Now that we have a market, how do we make it as efficient as possible? We need to be sure there aren't information asymmetries and that the switching costs [among products] are low. There are ways in which we can provide more information, transparency, and other [ways to influence the market.]
Blumenthal: As we reflect on the failings of our health care system and the limitations of our electronic health record system, I recommend that we look at other nations who have had major issues. "None of them has solved this information exchange problem." It's not technical nor political…"it is a human issue…deeply entrenched in human behavior..and fear of lost privacy…tribalism…and all kinds of things." With respect to the other issues, none of them have "cracked this nut." It's a matter of creating "incentives and systems that have social value."
Brailer: "Let's just bear in mind that the… FDA..is a major player ." The FDA will play a role in a matter of years and spoke of a "precedent for a regulatory framework." It will transform "in ways both good and bad" the way things evolve.
Lisa Simpson (Academy Health). I have a two-part question. How will health IT improve care and lower cost? What evidence do we need? Second, how are we actually going to have IT systems deployed that are not only a byproduct of care. So, what evidence do we need, how can we have "IT systems that are friendly to the evidence-generation process"?
Mostashari: Information technologies are different than other aspects of health care. Others have said we need the same standards as we apply to medications. But there is a fundamental difference. In much of medicine, we don't have an evidentiary base. But health IT can help us learn and "do it better." The one area he wishes more attention was paid to is to pay more attention to the "implementation science." It's not how it works, but "what are the context in which you can maximize" the impact? Much more study needs to be on making the "best be the norm." We have no "coordinated research and strategy."
Blumenthal: Every systematic review shows the positive contribution of information technology. My position is that the FDA had to review the evidence, it would approve it. Speaking of prescribing, adverse event, and clinical decision support, he says the evidence is there. But the "evidence doesn't measure what is important…a digital infrastructure that is a platform for unimaginable" progress and change. it is much more difficult to find cost evidence. It is going to take time to change. "I spent more time writing notes than learning how to write notes" and I "learned over 20 years how to make those notes better..by modeling from others." It was a long process. And now you "parachute a new approach" that is intended to change over the "arc of a lifetime." His two children - both residents - would not know how to take a paper note. In the future it will be more a matter of how to configure than how to learn.
Kolodner: We haven't seen the evidence yet. We should not have to copy and paste. But "we are talking about the research…remember that health care affects us in 15% of our health…we can optimize [this] but in terms of the overall goal…we can still miss things." The idea of having a person contributing data about their health that can inform us is very important. We are beginning to see an era of person-centered care." The real research is how to move things way back to learn how to prevent and to predict….this takes more resources."
From Carrot to Stick - "Meaningless Abuse" & the Need for Acccounatability
Gwendolyn O'Keefe (CMIO, Group Health). I am a proponent of Meaningful Use. How would you advise ONC to work with CMS with respect to the "stick" that represents the move from the incentives to the "nitty gritty details" of the CMS auditors. Some are now calling it "Meaningless Abuse." "My fear now is that [perception] is going to move from this is a good thing to this is yet another hammer."
Mostashari: "Now we are moving from theory to practice." [audience nervous laughter] He spoke of the conflict between the "intent and the "regulation." And he's right. When you pay out billions of dollars, you have to follow the rules. With the regulatory approach, "intent doesn't count." You don't trigger government funds "based on intent." But there is a duality. Meaningful Use is both a concept and a regulation. CIOs, forever, often misinterpret the regulations and, for example, promulgate the misbelief that you have to record smoking status on every visit. "We have to live in both worlds."
Blumenthal: "Farzad and I worked as long as we could to make this positive…but..I knew that the Office of the Inspector General and the Government Accountability Office was waiting to pounce." The biggest problem, some say, is that the public believes the government "wastes my money." So "we will always have accountability." It is incumbent on you [the audience] to help people understand the accountability. He reminds the group that accountability is also major issue in private insurance..and that this "falls on the patient." "We shouldn't expect to get the kind of money falling out of the MU program without any requirement that it is being used appropriately."
It's About Clinical Transformation
Thomas Powell (CMIO, U of AK): I wish you would have informed the CMIOS of this issue. "I spend the majority of my time translating…assuming well-meaning, well-intentioned individuals coming together." I find a worrisome trend that public figures believe doctors are difficult. This is not the case. What should be done to make sure the role gets translated to the right level.
Q (Petticort): What should the market do?
Brailer: We recognize that there are multiple segments of physician states of consciousness. Simplifying, there are those who are "totally into this," there are those who "are not going to do this," and there are those who are "the people in the middle; the 50% who were sitting on the fence." We largely ignored the first two groups and focused on the 50%. "I expect the role of the CMIO to adapt over time…but it doesn't scale…it has to be taken retail." The message has to be taken into "every corner." The "stresses on [the CMIO] are infinitely greater than HIT adoption."
Mostashari: At one institution, the CMIO leads the office of clinical transformation. "That's the right role…the right leadership type…it's about clinical transformation." But this CMIO spent a lot of time working with a large vendor where Mostashari felt that there were many others in the US with the same vendors who were doing the same thing. "The first things to do is to share the knowledge we generate."
Blumenthal: After ONC, I had a job at Partners as Chief Innovation Officer. He was responsible for the vendor choice for Partners. "I came away from that experience….the planning of that…more convinced than ever that the implementation of an EHR is the most important opportunity a health system will ever get to improve their performance…and opportunity for transformation." It is a "potentially transformative event." "If you tell your clinicians they can do it the way the record does it or the way they do it, but they have to figure out what their way is. Clinicians understand that "figuring out what their way is is a unique opportunity in the life of an organization." But you need the "clinical leadership…the independent leaders..to share that vision."
Kolodner: The role of the CMIO is currently one of getting the implementation going, but the role is changing. The work is done by other people. The CMIO role is that once people are comfortable with the resources, "the real innovation occurs out among the 15% of the innovators that are out there" who "coordinate and foster that innovation." The "transformation that will happen….will allow that innovation to go beyond the walls of the enterprise…and in fact [will occur] more broadly." The CMIO will become more of an orchestrator.
Pediatrics and other Priorities
Srinivasan Suresh, CMIO, Childrens Hosptial Detroit: Pediatrics has unique needs. "But the progress has been slow…we are the minority." State immunization registries are lower than the adult diabetes. What is the role of ONC to set [specific policies].
Mostashari: There is a challenge for ONC to think about behavioral health, home health, long-term care. This is one example. The role has to be broader than one of Meaningful Use enforcement. One thing that scales is "convening." That is a critical role.
Brailer: This question shows how "darned goofy" the government is. CMS is both a regulatory agency and the "biggest insurance company in the world." The overwhelming focus of CMS is to "protect the insurance company." He mentioned "conflicts of interest and distortions of reality." There is no better example than the "abyss" of pediatric policy making. But CMS doesn't focus on the many pediatric patients supported by CMS. But perhaps the [health insurance exchanges] will get them out of the "reality distortion field" addressing pediatric care.
Blumenthal: There are some Medicaid efforts involving children and there is some real incentive. But the Federal Government largely doesn't pay for the care of children. It's all about incentives and penalties as a payer. Most of this forces the adult patient world to adopt similar statements. But the issue is much larger. The questions are: who pays for the care of children? and how is quality care delivered? The Affordable Care Act is much more fitting for the care of children than Meaningful Use.
Kolodner: Government doesn't have as many levers for pediatric care. In general, we are still vendor-driven and not market-driven. But coordination and cooperation can help change the industry.
Seeking Shreds of Evidence
Q (Petticort): HITECH and it's relationship to the stimulus. How do you see organizations like AMIA and Academy Health have input into the policy side?
Brailer: I believe FDA will play a heavy hand. Organizations need to lay out the positions and the private-sector predicates. A lack of deep knowledge, information pilots, and other issues that inform policy will [hurt]. He hopes that some organizations will take up the re-formation of HIPAA and the mobility of data. ARA had some tune ups, but we need to see the current policy as an enormous inhibitor.
Kolodner: Looking around the world sometimes the informatics community is ignored and sometimes it is not. I am pleased that the informatics community has been an "integral part" of the national HIT agenda.
Blumenthal: "You should keep doing what you've been doing." The timing of HITECH was random, but it's occurrence was not. It was the product of decades of effort. The high quality of legislation was the product of many years of work. A lot of HITECH was "on the shelf" for a long period of time, including the term "meaningful use." [Success] requires the trust that with government, results can be positive. If you believe government can do better with shepherding information technology and policy one can have an impact.
Mostashari: We don't need more advocacy. We need evidence. The debate on Meaningful Use Stage 3 is the product of opinion and not data. The published literature is sometimes meaningful. There are 25 issues at least under MU-3. What can we do to produce at least "some shred of evidence" within the next nine months. "Stop doing papers about whether this thing worked or not." "I don't wan to know about the whether but instead about the how." If we fail because of the technology, "we will have lost an enormous opportunity."