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ONC Needs a Director

May 14, 2009
by aguerra
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In 2004, when President George Bush announced his vision that all Americans have an EMR by 2014, he set a long-term policy direction for the country. At that time, with a 10-year horizon to a deadline no one took literally, it made perfect sense to designate the leader of that effort as a ‘coordinator.’ With no rush, coordination was the proper way to go. It was a time of deliberately gathering stakeholders, receiving input and collecting concerns. Robert Kolodner, M.D., a soft-spoken, gentile man, fit this bill perfectly.

Coordination requires a specific skill set, an important skill set that is cultivated by the academic. Academics, you see, love consensus, hate telling anyone want to do, and revere polite cooperation above all else. They also, naturally, become “Adrift in PolicyLand.” In an environment of coordination, this is all good and fine. They can stay adrift as long as they like.

Today, however, HITECH has completely changed the game. Today, there are deadlines. Today, the actions of ONC (and its Policy and Standards Committees), NCVHS and CCHIT have implications to thousands that control millions. The implications are enormous.

Today, we need a director.


Directors aren’t always pleasant. Put a director in a coordinator role and all the volunteers will quit, taking their footnotes with them. Directors can be bossy at times, precisely because they have a vision already established in their minds. Good ones, however, leave that vision open to adjustment based on the discussions of the group. Directors are masters at leading those conversations, they are consummate conductors guiding talented musicians to a finale that achieves the stipulated goals.

Directors get things done.

Directors are skilled at discerning what needs to be presented the group (‘We will have four subcommittees, and here are your subcommittee assignments.’) as a fait accompli, versus what the group should be focusing on (‘This is what I would like to receive from each subcommittee at our next meeting.’). A director knows the proper size of a group for maximum effectiveness (19 for the Policy Committee and 21 for the Standards Committee is quite large) and structures meetings to ensure everyone is heard, rather than hoping those who want to speak are able to grab the conch.


A director has, above all other considerations, the mandate of the group top of mind, subordinating all pleasantries and sensitivities to that end.

But alas, at the point when ONC’s tight deadlines and wide mandate mean it desperately needs a director, it still has a coordinator, albeit a different one. Today, David Blumenthal, M.D., a self-proclaimed “life-long academic” is leading the most significant healthcare IT group ever assembled, and at the first Policy Committee hearing, he presided over polite chaos. As I look over my live Tweets from Monday morning (the 11th), I saw the problems early on. My first Tweet took place at 8:38, quickly followed by these:


Key (DB = David Blumenthal; AG = Anthony Guerra, designates my own voice)

first impression -- this panel of 19+Blumenthal is WAY too large8:43 AM May 11th

AG - scope too broad, too many members. Meeting today is only 3 hours, most of which is taken up in housekeeping. What can come of this?9:02 AM May 11th

AG - Crazy format - DB sets the stage with a 20 minutes overview of issues - then asks the 19 member committee: "What do you think?"9:15 AM May 11th

AG - another observation: Meeting has been on break for 15 minutes. Why do you need a break in a 3 hour meeting? only in PolicyLand10:13 AM May 11th

AG - things are being discussed at this meeting about PROCESS that should have been decided beforehand and laid out by fiat10:20 AM May 11th

AG - talk for a while now has been on how to set up subcommittees. For what issues? Who will be on them? How will they be managed?10:28 AM May 11th

AG - half hour left and I have no idea what directives will be going to the SC for their Friday meeting.10:29 AM May 11th

AG: for going on an hour, everyone trying to figure out how to set up four workgroups!10:40 AM May 11th

AG - figuring out what subgroups to have is becoming comical10:49 AM May 11th




David, I think I get Anthony's point about thisand I'm with you, I don't like bullies either. It's just that we have so much to do in this arena, and sometimes the business world is more adept at the process than the policy/legislative world. Gee, I couldnt' even imagine trying to bully Judy around!

Thanks for the comments.

Let's not get hung up on debating the specific merits of my alternative examples. What I am suggesting is that one needs to adjust their approach to the larger goals and deadlines involved. In my opinion, Blumenthal's current approach to this process is off the mark.

I would be much more concerned if we are two more meetings into this and they are still going over internal processes for their "group dynamics", so to speak. It is not unusual, in my mind, to have the initial meeting be about how the members of the group should work with each other and what the administrative rules of engagement should be. With poor communication protocols and lack of buy-in, this group could be doomed right out of the box.

I am with you totally, though, Anthony, that we have to move fast and be sure of foot as we move fast. But I also feel that when you are dealing with a group like this, the group may not be as motivated or innovative, if they feel they are just carrying out dictates from the leader.

The ideal would be to strike an effective balance that emphasizes the need for speed and inclusion, but is also absolutely unambiguous about the marching orders and the need to "do it right" the first time.

Anthony, I agree there could be more direction in policy land but please leave Gulliani and Trump out of the picture. They have good where they are, we don't need all the posturing.

I have a problem with the whole way Congress has structured this. Basically, we have two groups (Policy and Standards), not to mention NIST, NCVHS and HITSP, all trying to move towards something, but we don't know what that is because Blumenthal doesn't have a definition of meaningful use yet. This process would never take place under the stewardship of an effective CEO. I think I feel another blog post coming on.

I hope you're not suggesting they bring in someone like Giuliani or Trump to run this operation. That's definitely NOT change we can believe in! I get your point about people needing to be forceful, but they also have to be smart or else they just become bullies convinced of their own invincibility. We've already been down that road....