Replacing Farzad

In the wake of the National Coordinator’s announcement that he is departing, there has been a flurry of tweets, blog posts, impromptu online polls, and conjecture about the most likely successor.  To date, none of these conversations has resulted in a thoughtful assessment of the set of characteristics that would represent the ideal candidate, nor has there been any thorough review of the most likely candidates in the context of these attributes.  The need for a rapid transition to a successor is well understood by all – yet there has been no indication that the Obama administration is in a hurry.  Let’s hope that we can evolve them toward a greater sense of urgency. The fragility of ONC – and the importance of its health – can’t be overlooked.

Let’s consider some history:

The first two National Coordinators, David Brailer and Rob Kolodner, were appointed before ARRA.  The agency was small, focused largely on certification (through CCHIT), standards (through HITSP) and policy.  When ARRA arrived, David Blumenthal, a thoughtful, deliberate, policy-savvy internal medicine physician from Boston was brought in to lead the rapid expansion of health IT that was facilitated by the HITECH Act.

ONC expanded under Blumenthal from a team of ~ 30 people to a team of >100 in the two years that he was at the helm, and the agency published the 2011 certification criteria regulations, and collaborated with CMS to publish the regulations that defined stage 1 of the Meaningful Use incentive program.  The policy foundation was that the three-stage program – to be implemented over six years – would evolve the nation’s care delivery system by causing adoption of EHR technology (stage 1) and then exchange of clinical information electronically (stage 2) and finally improved clinical outcomes (stage 3).

Farzad Mostashari, who joined Blumenthal as the Deputy National Coordinator early in Dr Blumenthal’s tenure, was quickly named as Blumenthal’s successor when Blumenthal announced his resignation in the Spring of 2011.  Both Mostashari and Blumenthal pushed hard for Mostashari’s appointment – so that the consistency, focus and forward momentum of the organization could be maintained.

And so it was.  Under ARRA, adoption of EHRs has skyrocketed.  The CMS MU Stage 2 regulations and the ONC 2014 certification regulations were published, and the size of the agency has doubled to over 150 people.  Recognizing the need for experienced partners to assist him in leading a larger agency – and growing national reliance on health IT and an essential component of the care delivery ecosystem – Mostashari hired David Muntz as the “Principal Deputy” (essentially the COO of the agency), Jacob Reider as Chief Medical Officer (leading a team of clinicians focused on quality and safety) and Judy Murphy as the Deputy National Coordinator for Programs and Policy (adding internal coordination support for ONC programs).

All three of these new additions brought unique skills and experience to the agency:  Muntz, with a deep technical background, decades of leadership and business experience, and a soft, accommodating demeanor;  Reider with experience in hospital and ambulatory health IT implementation – as CMIO of a hospital and a large ambulatory practice, and with intimate knowledge of the “vendor world” – having served as the CMIO of a large EHR vendor, and a member of the executive team of EHRA – the vendor trade association; Murphy with decades of health IT selection, implementation, and tactical management experience in a very large hospital system, where she rose through the ranks from staff nurse to the leader of EHR implementation.  These three new leaders augmented the existing leadership team of Jodi Daniel (Director of Policy), Douglas Fridsma (Standards and Technology) and Joy Pritts (Privacy and Security).

The era of Mostashari, while viewed externally as an ONC that is run by a charismatic, visionary leader (and many news reports seem to focus on the supposed vacuum that he is leaving behind) was in fact not at all dependent on the National Coordinator for day-to-day operations.  Mostashari built a strong team of seasoned leaders who have been keeping the agency running day-to-day for the better part of two years.  This is not to diminish the vision, political acumen, or powerful leadership role of Mostashari.  All of this is valid and important.   But while Mostashari will be missed at ONC, most of the staff there understand that it is the “SLC” – the Senior Leadership Council – that runs the agency.  What was managed by Blumenthal alone – with input from Mostashari – is now managed by Muntz, Reider, Pritts, Murphy, Fridsma, and Lisa Lewis (Deputy National Coordinator for Operations).

The national stage is set well for significantly improved exchange of clinical information, as stage 2 increases the interoperability requirements for certified systems, and makes exchange requirements in meaningful use.  If Stage 1 was about adoption – it has succeeded.  Stage 2 – set to begin in 2014 – will be about exchange.  So far, the blueprint that Blumenthal expressed is being achieved – albeit slower than initially planned.

But not all is rosy at ONC.  With the end of ARRA funding, which supported most of the outreach and engagement programs at the agency, there are disagreements in HHS about how the agency should plan and implement its future.  Nearly 1/2 of the staff in the agency are working on managing the grant programs that will end within the next six months:  the REC program, the state HIE program, the Beacon program, and the SHARP grants.  By ONC’s measures, these have been successful, have facilitated the adoption of EHRs (over 75% of hospitals and providers now use an EHR) and have provided valuable “feet on the ground” feedback to ONC about the consequences – both intended and unintended – of the Meaningful Use and standards and certification regulations.

What’s next?  As ARRA funding winds down, and Mostashari departs, what shape will ONC take?  Does the agency compress back to 50 people who will manage certification, policy and standards, as it did in the pre-ARRA days?  How will ONC guide the industry through the all-important “exchange” stage of Meaningful Use?  How will ONC assure the public that this new technical infrastructure for our care delivery system is as safe as it could be?  How is the next wave of regulations going to assure the nation that clinical outcomes will really improve?  Without the improvement of clinical outcomes – is this whole “health IT” thing worthwhile?  Probably not.

All of these pivotal questions need to be answered, and one could argue that the next National Coordinator will have a much harder task than any of the four predecessors.  Without the wind of ARRA in the sails, and entering the “trough of disillusionment” that any product category will endure, the work of facilitating meaningful exchange, and delivering improved outcomes through the use of health IT will be a thankless and sobering task.  This is not a job for the faint-hearted.  It is not a job for an evangelist.  Mostashari, a brilliant man by all accounts, knows that the National Coordinator of a post-ARRA world needs to be someone else.  The needs of the agency are different.  He’s done his part well.  It’s time to move on to the next leader – with different skills – for an agency (and a nation) with different needs.

What are these needs – and the mirror-image strengths that such a National Coordinator must possess?

Let’s begin with the easy ones:  as the leader of a federal agency – the National Coordinator needs to have the character that will enable him or her to be effective in government.  This would include strategic insight, vision, focus, pragmatism, candor, integrity and humility.  A pragmatic, thoughtful leader for tomorrow will listen more than they speak, which was the style of Dr Blumenthal, but not Mostashari.  It’s time that the volume gets turned down a bit.  Confidence is great, but hubris can be alienating, and the success of this transformation will rely on a collaborative, engaged leader who seeks to understand before seeking to be understood.

Management.  None of the previous National Coordinators had especially strong management skills.  A great leader hires others to augment his or her weaknesses, and this is precisely what Mostashari did.  So while management at the leadership level is important – as Mostashari has demonstrated – it can be purchased.  If Muntz leaves ONC, and the new NC isn’t a strong manager, a replacement Principal Deputy will need to be hired, and while people like Muntz don’t grow on trees, the essential skills that he brings to the agency are the skills of a capable, loyal COO – and there are good candidates in both government and industry who could augment a National Coordinator in this way – just as Muntz has for Mostashari.

Politics.  Washington is a polarized city, and a political appointee leading such an important agency needs to understand the political consequences of every action and inaction.  While political skills and insight can be taught, this is more likely to be an attribute of a candidate that is innate, rather than learned.  Either someone thinks this way or they do not. It’s important that the next National Coordinator have some political aptitude.  Experience is a plus, but with good aptitude, and seasoned DC advisors to help navigate the minefield that is Capitol Hill, a National Coordinator can be very successful.  Politics isn’t so hard as it looks:  be humble, focused, honest and clear about your intentions.

Physician.  There is debate about whether the next National Coordinator needs to be a physician.  There is no legal or regulatory requirement that the position go to a physician, yet there is a track record:  all four previous coordinators have been physicians.  The advantage of a physician in this role is that the most important users of EHRs today and tomorrow are physicians.  Yes: nurses, physical therapists, pharmacists, patients, paramedics and many others will interact with these products in many ways.  But if physicians don’t embrace health IT, it will fail.  Given the nature and culture of our medical community, it is very likely that the next National Coordinator will be much better positioned to succeed if he/she is a physician.  Essential?  No.  Preferable?  Yes.   In the case of a non-physician National Coordinator, the role of the Chief Medical Officer, currently occupied by Reider, becomes increasingly important.

Health IT software development experience. ONC regulates an industry.  That industry creates software.  Should the National Coordinator understand how software is developed?  Should the National Coordinator have experience in this domain?  Neither Blumenthal nor Mostashari had this experience, while Kolodner and Brailer did.  Just as practicing physicians can understand viscerally what it’s like to endure a poorly designed EHR, an experienced software developer understands the opportunities and limits of technology, and knows just how hard to push the limits.  Push too hard – or in the wrong places, and the technology will break.  Badly designed features are worse than no features at all.

The 2011 certification criteria were widely criticized for being disconnected from the reality of software development life-cycles, technical capabilities of health IT developers, and (in the area of quality measures especially) ambiguity of the requirements.  With the addition of Reider to the ONC team in 2011-2012, as the 2014 certification criteria were being written, industry observers  noted that the regulation – while still quite demanding – didn’t smack of naiveté as did the previous edition.  Essential?  No.  Preferable?  Yes.

Health IT day-to-day use experience. We’re past adoption. Most clinicians are active users of health IT today.  Three years ago, it was acceptable for a National Coordinator to be someone without this experience, because only a minority of clinicians was using EHRs.  Today, It’s not acceptable.  The National Coordinator needs to know how it feels – needs to know what it’s like to use health IT in a busy office or hospital.  Needs to have experienced the thrill and frustration with what the EHR can do for/to a clinical day in the life.  Essential?  Yes.

Health IT implementation experience.  “Adoption” and “successful adoption” are different animals indeed. The industry has seen many examples of both – and one vendor (Epic) has accumulated an extraordinary share of the hospital market as a product of their track record of successful implementations.  Epic doesn’t allow their customers to fail.  The National Coordinator needs to understand the attributes of success from personal experience.  This isn’t something that can be read from a book, or gleaned from a meeting with vendors, hospital executives or angry physicians.  Success is about changing the culture of an institution – and a National Coordinator who has changed cultures locally is much more likely to be successful changing a culture nationally.  Essential.

HIT implementation – small scale. A variant of implementation is the implementation that occurs in an office with one or two clinicians – or in a remote hospital with a handful of beds.  Has the National Coordinator experienced the challenges of implementing IT in a resource poor setting?  Can She/he describe how to overcome such hardship?  This is a rare and important set of experiences.  Essential?  No.  Optimal?  Yes.

Policy Vision.  The National Coordinator is the voice of ONC as the agency aligns its policy with other HHS agencies and beyond.  It’s imperative that the National Coordinator have a vision that she/he can explicitly define, and eloquently express to her/his counterparts in public and private organizations.   The National Coordinator should be a strong public speaker who can manage congressional testimony, hill briefings, conference presentations, media appearances and public listening sessions with ease.

Trusted by federal partners (CMS, AHRQ, NLM, CDC, FDA, NIST, VA/DOD).  ONC has a pivotal role in helping to shape the future of Health IT. Many other federal agencies have a vested interest in what shape becomes, and how it is formed. Historically, the relationship between ONC and some of these agencies has been strained.  The ideal National Coordinator will be a strong representative of ONC’s vision and will collaborate with other federal agencies toward shared success.

Trusted by ONC staff (continuity, retention).  At this pivotal time, ONC needs to retain the momentum and the subject matter expertise it has built over the past several years. Widespread attrition could cause problems throughout ONC and as a byproduct throughout the industry.  The next National Coordinator will need to be trusted by members of the ONC team and capable of coalescing this group toward the operational excellence that they have sought but have not yet achieved.  The transition from ARRA funding to a post-ARRA state is causing a great deal of anxiety throughout the agency already.   If the staff do not trust the next National Coordinator, even before he or she joins, there may be widespread attrition due to the uncertain fate of the temporary positions that were created under ARRA.  The continuity of an internal candidate would likely result in greater retention of essential staff, which would reduce the risk of widespread attrition and the instability of policies, standards and certification programs that would occur as a byproduct of unplanned attrition.

As we consider the candidates who might share many of the attributes outlined above, it is important to consider that there are a set of less tangible qualities that are also important. Such attributes include political connections to the White House and the Obama administration, personality, integrity, and industry reputation.

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