In recent weeks, an atmosphere of concern among healthcare IT leaders nationwide has turned to one of increasing alarm, as virtually all the senior officials at the Office of the National Coordinator for Health IT (ONC) have either departed or shifted focus, at a moment when issues around Stage 2, and the upcoming Stage 3, of meaningful use, have been piling up one after another. So much is happening now that one needs a scorecard simply to keep track of who’s left and what’s happening. So here’s a quick summary:
On Sep. 22, ONC announced that Doug Fridsma, M.D., Ph.D., the agency’s chief science officer, was leaving to become president and CEO of the American Medical Informatics Association (AMIA).
On Oct. 3, ONC announced that Judy Murphy R.N., the agency’s chief nursing officer (CNO) and director of its Office of Clinical Quality and Safety, was leaving to become CNO at IBM Healthcare Global Business Services.
On Oct. 23, Sylvia Mathews Burwell, the Secretary of Health and Human Services (HHS), announced that Karen DeSalvo, M.D., National Coordinator for Health IT had been tapped to serve as Acting Assistant Secretary for Health, in order to support the Obama administration’s Ebola response, and was “stepping away” from her duties as National Coordinator, while technically retaining the title.
On Oct. 24, ONC confirmed that Jacob Reider, M.D., Deputy National Coordinator for Health IT, was leaving the agency. The announcement of Reider’s departure occurred exactly 17 days after Reider had denied publicly to me at the iHT2 Health IT Summit in Washington, D.C. that there was any pattern in the ONC departures up to that point, stating for the record that “no hemorrhaging” was taking place at the agency. When Reider made that comment on Oct. 7, Fridsma and Murphy had already left ONC, as had Joy Pritts, the agency’s chief privacy officer (June 12), and Lygeia Ricciardi, head of its Office of Consumer eHealth (June 26); but DeSalvo had not yet “stepped away,” and of course, he himself had yet to make his announcement.
On Oct. 29, following widespread expressions of dismay and confusion in the industry regarding the DeSalvo Ebola management announcement, ONC published a blog in which the agency stated that “Dr DeSalvo will serve as Acting ASH while maintaining her leadership of ONC. Importantly, she will continue to work on high level policy issues at ONC, and ONC will follow the policy direction that she has set.” Just days earlier, Jeff Smith, vice president of public policy at the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME) had written in his Washington Debrief on this website, “Health IT leaders were shocked last week to learn the top two health IT officials from the Obama administration are leaving their posts,” referring to the DeSalvo and Reider announcements.
“DeSalvo is leaving the office at t a critical time, with MU attestation numbers below historic levels, and big policy priorities related to interoperability and Stage 3 yet to be finalized.” DeSalvo had gone so far as to announce in a committee meeting that she would no longer attend any committee meetings; but HHS and CMS (Centers for Medicare and Medicaid Services) officials quickly walked back that statement, reassuring healthcare leaders that DeSalvo would remain active in her ONC work while also dedicating her efforts to her Ebola preparedness work.
In his Oct. 27 Washington Debrief, CHIME’s Smith noted that fewer than 10 percent of hospitals scheduled to meet the Stage 2 requirements of meaningful use had done so as of that date, and fewer than 2 percent of eligible physicians had attested to Stage 2 at that time. Meanwhile, the development of an interoperability and patient safety roadmap was at that point (and still is, a week later) in its very early stages.
Why It Matters
The departures (including the “stepping away” of DeSalvo as National Coordinator) are not only alarming in and of themselves, but have two additional elements to them that are causing industry observers and healthcare IT leaders to become increasingly nervous, with some calling for drastic federal action of a variety of types.
This morning (Nov. 4), at the Policy Committee meeting, DeSalvo thanked the Policy Committee and ONC staff for their support during this period when she was asked to “lean in” on helping with Ebola and other public health issues leveraging resources of Office of the Assistant Secretary for Health (OASH), the part of HHS that includes the Surgeon General and the Commission Corps of the Public Health Service. She said 71 Commission Corps members are in Liberia now standing up a hospital to serve healthcare workers who are working in hospitals in Liberia should they become sick.
She thanked the ONC team for continuing to execute every day. “The work is not lower priority and not stopping. I really feel the need to reassure that for folks personally on behalf of the Secretary. Health IT and ONC remain a priority for this department and this country,” she said. “If anybody wasn’t certain that it was a part of her top priorities, she certainly has it completely woven into delivery system reform, which is at the very top of her agenda.”
These statements are all well and good. But if, as referenced above, if one includes Dr. DeSalvo's now-partial attention to her core agency, nearly the entire top level of ONC officials has now left the agency entirely or has “stepped away.” That is a level of decimation of ranks that simply cannot go unremarked upon in itself. Further, in a wide variety of conversations I have had with very highly placed Washington and nationwide sources in the past few weeks, I have learned of an atmosphere at ONC that my sources describe as one of intense discouragement, disillusionment, and distraction. Those close to the agency say that the culture within the agency has deteriorated to the point at which internal disorganization and instability have taken their toll on the morale of those remaining, at a moment when sustained leadership and concentration are needed more than ever. Highly placed sources have hinted to me at broader aspirations on Dr. DeSalvo's part. In any case, they have said they believe strongly that, ONC’s blog-based protestations notwithstanding, she has no intention of being more than technically in charge there, as her attentions are now divided between her HHS work around the high-profile Ebola crisis and a potential political career. That leaves her status as intensely ambiguous, at the very least.
My sources tell me that Lisa Lewis, ONC’s chief operating officer, who is taking on the National Coordinator duties in the wake of the “stepping away” of DeSalvo, is a highly talented and dedicated manager, and that she is well-regarded by her peers. That said, Ms. Lewis has no healthcare- or healthcare IT-specific background, and her lack of deep background in healthcare and healthcare IT can only be seen as an extreme disadvantage at a time when the meaningful use program under the HITECH Act is going into its most intense period to date, with a number of questions remaining around how to handle the very low attestation rates of hospitals and physicians under Stage 2, and concerns over Stage 3 development at a fever pitch in the industry.
Today’s numbers certainly won’t help. We’ve just learned that only 840 hospitals have attested to Stage 2 within the 2014 calendar timeframe, out of the 2,300-plus hospitals that had attested to Stage 1; and the number of physicians attesting to Stage 2 within the 2014 calendar timeframe is tiny, at 11,478. ONC and CMS officials need to make a very important calculation quickly about how to handle these pieces of news, because without some kind of remedial backstopping here, massive numbers of hospitals and physicians will face penalties after 2017. Even the awareness of that fact could further discourage healthcare leaders going forward, as they also need to direct their attention to the ICD-10 transition and to the mandates under the Affordable Care Act to participate in value-based payment and readmissions reduction, mandates that are demanding attention of CIOs, CMIOs, and their colleagues nationwide and that potentially involve, along with HIPAA-driven data security mandates, potentially more attention than even meaningful use itself.
Now, let’s talk about Stage 3 of meaningful use. As Intermountain CIO Marc Probst told me on Oct. 29, when we met during the CHIME Fall Forum, held last week in San Antonio, “I’d like the Policy Committee to focus on interoperability, and to put all the emphasis on interoperability in Stage 3. The vision, the framework, that’s been laid out is terrific.” But, he added quickly when asked what would happen, “I think meaningful use Stage 3 will be about something different from just interoperability, and that will be very frustrating for the market. I also worry about whether meaningful use can withstand this transition. And that’s not just because of Karen’s partial departure and situation. It feels as though Washington just won’t listen,” he told me bluntly, referencing specifically the widespread calls for a 90-day attestation period for Stage 2 in 2015, which have been “ignored,” as he put it.
Probst, a board member of CHIME who is on the policy committee, and who described himself as a “big-time Karen DeSalvo fan” and an admirer of Judy Murphy, said bluntly, “I would describe meaningful use Stage 2 as a meager success, if that; and so 2015 is going to be a very bad year for meaningful use, and the odds are slim that organizations are going to meet the requirements, now that October 1 has passed. I also believe that if meaningful use Stage 3 is not completely focused on interoperability, that the industry is just going to say, you guys are out of your minds, you know?” Overall, Probst told me, “Meaningful use has put technology much more broadly into healthcare, and raised the discussion, and that’s good, and I think that raising the technology level is good.” But, he added quickly, “I honestly think we should now declare victory and move on. I’m not a fan at all of how we’ve defined meaningful use, in terms of checklists and such.”
Probst’s sentiments were widely echoed by everyone I spoke to on the subject while at the CHIME Fall Forum. There is widespread dismay over all the leave-takings at ONC at a time of incredible pressure on the industry, and a sense of impending doom among many that Stage 3 MU will be a complete disaster; and I should underscore that the people making these comments to me are far from your high school drama queen types; indeed, they are among the most sober, thoughtful IT leaders in the industry. What’s more, several healthcare IT leaders I’ve spoken with are among those openly questioning ONC’s ten-year interoperability plan. As several have said to me recently, “What’s with the idea of a ten-year plan for anything, anyway? It’s time to move forward rather than to create such long-term plans.”
So here are my five questions for federal healthcare officials, at ONC, CMS, and HHS:
What is Dr. DeSalvo’s authentic leadership and management status? The industry deserves to know the unvarnished truth. If she has in fact relinquished effective leadership of ONC, federal officials should be upfront about it and say so, and should replace her with someone qualified to be National Coordinator and who can lead the agency forward through MU Stage 2 and into Stage 3 with credibility and with support from the industry.
Federal health officials need to clarify the true situation with regard to the repercussions and implications for the very low level of Stage 2 attestation on the part of hospitals and eligible physicians. If not, the MU program will move forward into Stage 3 under a dark cloud of uncertainty.
Right now, there is absolutely no clarity regarding the overall approach to MU Stage 3. Given the leadership and management vacuum at ONC, federal health officials at HHS, CMS, and ONC must clarify at the absolutely earliest moment the true and full direction of Stage 3.
Drilling down one level, federal health officials need to clarify immediately whether Stage 3 might be trimmed down to primarily or exclusively focus on interoperability, which is being urged by most provider leaders nationwide. If Stage 3 requirements are to be broader, an authentic map needs to be laid out as quickly as possible, at least in principle, for the industry, even if the formal committee processes need to roll forward according to formal timetable. Fundamentally, many in the industry have a basic question around Stage 3. Could we not whittle Stage 3 requirements down to an absolute minimum, and make those focused around interoperability? A very complex menu of Stage 3 requirements really could make the remainder of the program virtually impossible for most providers to meet. Fundamentally, at this point in time, is the industry really capable of managing and mastering an intensely challenging Stage 3? And what about the anticipated penalties at the conclusion of the program?
What is the broad vision for the role of ONC going beyond the meaningful use process itself? What is strongly needed is a full-time, fully dedicated National Coordinator who can articulate a vision that moves the healthcare IT sector forward beyond 2017 and into the next several years for the industry. Part-time leadership will not give the field what it needs in that regard.
My grave concern is that ONC as an agency could be entering a period in which it is essentially adrift, at a critical time for the healthcare industry and for our society. The meaningful use program under HITECH has brought about absolutely needed change and spurred the healthcare industry forward in numerous important ways. But MU is now seriously (hopefully not fatally) impaired, and ONC, which has provided essential leadership for IT leaders across healthcare, if disabled as an agency, could prove ineffective in helping to guide our industry forward at an absolute inflection point going forward, when issues around interoperability, data security, health information exchange, clinical transformation, and technological change are more pressing than ever. What’s more, healthcare CIOs, C MIOs, and other IT leaders remain dismayed by the feeling that ONC, CMS and HHS officials simply aren’t listening to their legitimate concerns. The bottom line? The healthcare industry deserves strong leadership from our federal healthcare agencies going forward—and is collectively demanding answers to these important questions.