Five Recommendations for an ONC Head Who Understands Health IT Innovation

Now that the legislative language of the HITECH Act — the $20 billion health IT allocation within the economic stimulus package — has been set, it’s time to identify a National Coordinator (NC) for Health IT who can capably lead that office. As many now realize, the language of the Bill can be ambiguous, requiring wise regulatory interpretation and execution to ensure that the money is spent well and that desired outcomes are achieved. Among other tasks, the NC will influence appointments to the new Health Information Technology (HIT) Policy and Standards Committees, refine the Electronic Health Record (EHR) technology certification process, and oversee how information exchange grants and provider incentive payments will be handled.

Previously we have described our concerns with US health information technology and the policy agenda that has
grown up around it. In the case of EHRs specifically, the tools that have been developed to date are often non-ergonomic, excessively costly, non-interoperable, and interruptive of practice work flows. They continue, in many cases, to use client-server rather than Web-based technologies, creating barriers to lower cost and easy data exchange. Most important, these issues are obstacles to the organic, market-driven development of a nationally compatible health IT platform. In large measure, they have resulted from the protectionist influence of powerful health IT firms whose interests would be best
served by approaches that build on proprietary and pre-Internet health IT designs rather than upon innovation that would move health care closer to e-health.

We believe the key question for the Office of the National Coordinator (ONC), as the Secretary of HHS’ principal Health IT adviser, is centered on whether and how health policy encourages innovation. Will the NC promote desperately-needed progress in the development, implementation and use of health IT, or constrain it under well-meaning but often
over-zealous certification and standard setting? Will we buy innovative tools that let both providers and patients achieve better quality and lower cost, or buy yesterday’s expert systems that resulted in our current problems?  Will we facilitate and build on incremental solutions, or continue to delay action through endless expert panels, meetings, and rules-setting exercises?

The aperture of innovation can be opened much wider than it has been. Here are five individuals, each of whom, we believe, as National Coordinator, would encourage innovation and change from the status quo. All of these people have demonstrated a vision of health care connectedness, quality, and efficiency that are in the common, rather than the special, interest, and each has the administrative skills and savvy to bring that vision to fruition.

Farzad Mostashari, MD MPH
Assistant Commissioner
Primary Care Information Project
New York City Department of Health and Mental Hygiene

Dr. Mostashari chairs the Primary Care Information Taskforce, whose goal is to bring about the adoption of public health-oriented health information technology in underserved communities. He is a primary care physician with the unprecedented experience of having rolled out EHR technology to physicians and medical practices serving over 30
percent of New York City’s Medicaid and underserved population
. Among the largest and most successful EHR implementations in the country, this effort has included 1,500 public and private sector medical practices, rather than simply one large enterprise. An epidemiologist, Dr. Mostashari understands data and has the statistical expertise necessary for decision making at the individual, community, and population levels.

Dr. Mostashari has hard-won hands-on experience with implementing EHR technologies in the small and medium-sized medical practices that make up 75 percent of America’s medical community, as well as knowledge that extends to public health and preventive services. He would bring a pragmatic vision of connected health for all Americans.

Carol Diamond, MD, MPH
Managing Director, Health ProgramMarkle Foundation

Dr. Diamond chairs Markle’s Connecting for Health program, a public-private collaborative working to realize the full potential of information technology in health and health care. Among other significant achievements, she led the multi-year collaborative that produced the Common Framework for Networked Personal Health Information, the widely-endorsed (and current default) set of principles and practices that govern the exchange of personally identified health data among health care institutions, and between health care institutions and lay people. Dr. Diamond  works with many private sector groups, government agencies, and health information technology bodies. She played a role with federal agencies and the health IT community in the development of www.KatrinaHealth.org, a secure web site that made prescription medication histories available to doctors and pharmacists caring for evacuees whose medical records were destroyed in the hurricane.

If the new NC must possess particular skills, it will be those of mediator and coalition builder. With a deep understanding of the challenges and opportunities ahead, Dr. Diamond has led national health IT collaboratives that actually produce results people, provider organizations, and health IT companies, can use.

Peter Basch, MD
Medical Director for Clinical Ambulatory Systems
Medstar Health System

Dr. Basch, DC area MedStar Health’s medical director for e-Health, has been a leader in applying IT to the needs of physicians. An early EHR adopter in his own practice at MedStar Health, Dr. Basch now is directing EHR implemention

throughout all of MedStar’s ambulatory practices. He is a frequent writer, speaker and expert panelist on EHRs, interconnectivity, health care’s transformation through IT, and the sustainable business case for information management and quality. Dr. Basch served as the chairman of the Maryland Task Force on EHRs that recently issued its final report.

He has co-chaired the Physicians’ EHR Coalition, is a board member of the eHealth Initiative, and a member of the American College of Physicians’ Medical Informatics Subcommittee and Medical Services Committee.

With Dr. Basch, we’d get deep technical expertise, direct experience with implementation, credibility among practicing physicians and their membership organizations, an a voice that can represent primary care within large enterprises.

Carolyn M Clancy, MD

Director, Agency for Healthcare Research and Quality
Washington, DC

Prior to Dr. Clancy’s appointment on February 5, 2003, Dr. Clancy was Director of the Agency’s Center for Outcomes and Effectiveness Research (COER), then AHRQ’s Acting Director.  A general internist and health services researcher, she was a Henry J. Kaiser Family Foundation Fellow at the University of Pennsylvania. Before joining AHRQ in 1990, she also was an assistant professor in the Department of Internal Medicine at the Medical College of Virginia in Richmond. Dr. Clancy holds an academic appointment at George Washington University School of Medicine (Clinical Associate
Professor, Department of Medicine) and serves as Senior Associate Editor, Health Services Research. She has served on multiple editorial boards (currently Annals of Family Medicine, American Journal of Medical Quality, and Medical Care Research and Review).

Dr. Clancy has published widely in peer reviewed journals and has edited or contributed to seven books. She is a member of the Institute of Medicine and was elected a Master of the American College of Physicians in 2004.  Few people in DC have the credibility and respect that Dr. Clancy deservedly enjoys.

Carolyn Clancy has grace, patience, vision, and deep knowledge of health care processes. She hung on at AHRQ throughout the Bush years, clear demonstration that she understands and can skillfully negotiate DC’s landmines. And
perhaps as well as anyone, she understands the opportunities that lie ahead for evidence-based medical care in the United States.  That background would allow her to foster effective leadership and innovation throughout health care.

Adam Bosworth
CEO, Keas, Inc.
San Francisco, CA

Mr. Bosworth joined Google in July 2004, having left BEA Systems, and earlier, Microsoft. In early 2006, he gained widespread attention as being “architect, Google Health.” Bosworth is widely recognized as a pioneer and key figure in the evolution of extensible markup language, or XML, the standard upon which e-commerce most depends. Bosworth was a senior manager at Microsoft, where he drove the company’s XML program from 1997 through 1999. He was then named General Manager of Microsoft’s WebData organization, a team focused on refining the company’s long-term XML
strategy. While at Microsoft, he was also responsible for designing and delivering the Microsoft Access PC Database product, and he managed the development of the HTML engine used in Internet Explorer 4 and Internet Explorer 5.  He is one of the most successful software engineers of the past 25 years, chief product manager for numerous well-known products that have changed our every day world, including Internet Explorer, Microsoft Access, extensible markup language XML, and Google Health’s Personal Health Record.

Over the last couple years, Mr. Bosworth has impressed health care audiences with the scope of his knowledge and vision for how more broadly conceived health IT could positively shape the supply, delivery and financing of health care. An
outside-the-box candidate par excellence, he has complete fluency in how software and standards for data exchange
work. Although relatively new to the health care sector (compared with our other recommended candidates), Mr. Bosworth’s unparalleled technical expertise, history of consistent innovation, and his fresh approach to health care’s structural problems might be just the infusion the industry needs.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies. Brian Klepper PhD is a health care market analyst and a Founding Principal of Health 2.0 Advisors, Inc. John Moore is a Principal at Chilmark Research.

14 replies »

  1. I was surprised to find Mostashari on the list. I think we need a reputable leader who can lead by example to fill this critical role. We need someone who has a strong sense of responsibility and accountability. We need someone who is honest and reliable and does not overstate his achievement, especially in front of the news media.

  2. What about a CIO with real-world experience? Marty Harris at the Cleveland Clinic? John Glaser at Partners?
    Of your five, David, I’d give it to Clancy. Surprised not to see a unanimous cheer for Carol. She’s a deft leader, visionary yet pragmatic, and has humor, grace and intelligence to spare. She understands health IT’s promises and limitations, and will push smart solutions. I know the AHRQ HIT portfolio has not been stellar…but it has done some innovative work. Go Carol.

  3. I find it ironic you chose to pick all physicians except for Mr. Bosworth. I’m perplexed by the assumption that the NC needs to be a physician. I can’t disagree more. It’s been my experience that the physician is the least likey to use the EMR technology in his office in some meaningful fashion. The nurse and the front office people spend much more time bridging the interface between patient and system than do the physicians. Another reason why I feel a physician is a generally a poor choice…physicians, by training, are very risk averse and tend to cast a very conservative lot against innovation. That’s not to say that a clinical base is not important…it is. However, I can think of many other clinicians who have to master technology more so than the physician. If I were to pick the center of the universe for patient care, I’d pick the nurse. (no, I’m not a nurse but am a clinician).
    If anything, the current or next NC NEEDS to be innovative beyond measure. He/She needs to create harmony across the stakeholders and most importantly needs to engage not just the federal stakeholder but develop programs that are compelling to the private sector because they will advance connectivity between practices through systems.
    Notice I didn’t say interoperability. We need to actually connect systems in advance of true semantic interoperability. These EHR’s need to be able to find not only a patient’s record in one system, it must be able to discover and retrieve records in every system that matches to the patient. That does not involve interoperability. It involves a common set of service interfaces. This is where works of the NHIN, IHE, HITSP, CCHIT and HL7 come together. Interoperability will be the natural by-product driven by usability.

  4. David Kibbe, is it modesty that prevents you from putting your own name on that list? If so, let me put it there for you! Charles Sneiderman MD PhD, NLM (personal endorsement, not on behalf of Uncle Sam!)

  5. Add my friend Prof Ross Koppel from the University of Pennsylvania who has a duel appointment in Penn’s Dept of Sociology and School of Medicine who understands the essential importance of sociologic input to HIT
    Dr. Rick Lippin

  6. David,
    I think the aperture can not only be opened but reinvented-beyond polaroid to digital, beyond revolutionary to rebellious! Appending what exists (for the most part) is not the answer; in my restricted N=1, we need insurrection and possibly your 5 nominations are the leaders for that insurrection. Don’t be reticent, you can be the force of reason and a powerful leader for these five and others. We need an omnipotent leader and guerillas who are willing to do more than ‘improving’ systems that barely work but innovating with ‘quality and efficiency’. We seem to keep forgetting “it is the patient, stupid”.

  7. Great to see Farzad on this list. He’s the only one I’ve had direct experience with, and I think he’d be a great choice. Completely qualified, with a good sense of vision about the public health potential of EMRs, and as the authors cite, a lot of experience implementing EMRs in small physician practices, which is the key hurdle.

  8. Amazing what you can do once you have money. As I recall Lori was at ONC with Brailer during the time the RHIO model was tried and failed and certification didn’t get off the ground then she went to work at Manatt in 96.
    The best predictor of success is past behavior. I don’t track all of these people but what specifically has she done that is creative? How many EMRs or web based applications has she developed, implemented or optimized?
    Has she has ever worked in a hospital, doctors office or implemented a single HIT application or developed a new program? Young and aggressive, she understands the importance of interoperability and is a great administrator but far from creative based on her record.

  9. Lori Evans has shown extraordinary leadership, vision and collaborative skills in leading New York States rapid movements towards building a statewide infrastructire that serves as a model for other state efforts as well as the national health information network. She has lead efforts to bring diverse groups together in the New York e-Collaborative where representatives from all stakeholder sectors as well as vendors have worked successfully with the NYS department of health to develop statewide policies and a technical framework. The experience gained from handling the large amounts of grant funding in New York State to move things forward is also excellent background for the ONC position. She certainly is on the short list and will make a wonderful, experienced leader if chosen.

  10. If you pick a MD to lead a technical program it will be sure to fail. Look how many EMR, RHO, lab integrations, etc. that have failed or are failing. I have worked on many project where MD were in charge of technical solutions. Most do not have the skill or the objectivity to provide technical solutions. To close to the problem. MD need to develop the requirements but not lead the solution. Let software engineers solve your software problems.
    Doctors have to much control of what happen in the healthcare industry and look what that has got us.
    Adam Bosworth is the only candidate with the qualifications to lead such a endeavor.

  11. I also heard that Dr. Kevin Hall the innovator of the first DoD electronic health record was under consideration as well. If not, he should be.

  12. Having worked at a Medical Records department of a major Hospital in the State of Michigan for 27 years,
    I can forsee and see presently dangerous problems stemming from the improper usage of the EHR ( for Patient Care). Because in my opinion there are so few regulations on the releasing of health record information from hospitals for patient care, other than Confidentiality regulations, if the new user rules (assuming they are correct),for patient care faxing are adopted then I believe they should be used at all major and smaller hospitals.
    So many times, I have seen management wanting to everything “they’re own way”.

  13. What a great list of very talented individuals. The authors could add themselves to the list. I think it’s critical that a PCP’s perspective be part of the mix as these pilots and standards move forward; so Dr. Kibbe, short list yourself!