Time for a summer vacation at ONC

I’ve spoken at some length about my enthusiasm for the current leadership at HHS and ONC. President Obama has both directly and indirectly engaged some really gifted individuals to help us address healthcare challenges through the use of information technology --- which is awesome. In particular, folks like Aneesh Chopra, Todd Park and Farzad Mostashari have brought the Internet to healthcare (or perhaps more accurately, healthcare to the Internet), and have convened some super-effective public/private groups to collaborate on specific issues with real success. I’ve had the good fortune to participate in a few of these, and it’s been some of the most rewarding work of my career.

Truth is, I’m not used to seeing such great work out of government. So I’m a bit reluctant to throw out what could be perceived as a negative message --- but after my own two-week vacation thinking about it I’m convinced the time is right to ask ONC:


Why stop now? I think the answer is increasingly clear. Between Meaningful Use Stage 1, the Direct Project and the Health Data Initiative, government has kicked industry out of a funk it’s been in for the previous decade, and we’re seeing a ton of really exciting and positive innovation. But nobody, and certainly not ONC, knows at a detailed level how to turn that innovation into ubiquitous market reality. What we need now is a period of implementation, competition and iteration to figure out how to deliver on the promise.

I’ll use the Direct Project as an example because it’s the one I’m most familiar with. Two really amazing things happened after the FACA hearings of late 2009:

  1. ONC clearly affirmed that current regulation supported point-to-point information exchange over the Internet. Separating policy from technology gave private industry confidence that if they built the software, they could credibly deploy it in a timely (and profitable) way.
  2. ONC adopted a “Do-ocracy” approach to the project, which dramatically changed the dynamics of power. The most influential voices were those that were prepared to take the solution to practical reality. Running, scalable software --- not standards --- was the goal.

These two actions --- constantly reinforced by the remarkable diplomacy of Arien Malec --- set the stage for the rapid development of the Direct protocols and reference implementations. Microsoft and other vendors put their resources behind this project because the government made it possible for industry to succeed where it had failed alone.

OK --- so fast forward to today. A number of Direct-based pilots are underway implementing the “stories” we used as our guideposts, primarily provider-to-provider referrals and delivery of visit summary information to patients. National groups like the AAFP are creating web-based utility services that will be available to small providers, and states like Rhode Island are crafting the scalable policies necessary to sign up large and small organizations in a regional circle of trust. But even more exciting are the unexpected ways in which Direct is being leveraged:

  • Within days of launching Direct, Microsoft was receiving requests from providers to enable bi-directional messaging with their patients from HealthVault.
  • As part of its phased exit from the market, Google Health has implemented Direct for its users to conveniently move their health information to other PHR services like HealthVault --- effectively mitigating potential fears about “lock-in” by private PHR services.
  • Direct is supporting structured exchange of ubiquitous HL7 V2 messages for immunization data, and has been proposed as a means to execute efficient and secure distributed population queries --- as well as “break the glass” emergency requests.

The point is, there are a ton of ideas and trials --- all bound by and compliant with existing regulation --- happening in all corners of the industry. Some will work and some will fall by the wayside, and that’s OK, because we’ve escaped the funk and are making progress again. It’s an incredible success story for guided capitalism.

So then, what am I whining about?

As Todd says, people come and go but government process is forever. Sometimes that’s a good thing, but often it isn’t. If people keep meeting, they have to keep doing something, right? For example, the Privacy and Security Tiger Team is still out there, so ONC asks them to make recommendations on stuff. Most recently it was to recommend policies for how the federal agencies should manage certificates for Direct (certificates are technical doohickeys that help us ensure that only the right people receive and can read information using Direct).

Well, they did exactly what they were asked and made a recommendation. Unfortunately they didn’t have all the right context and information to make the decision. Really, right now nobody does --- remember, separating the policy problem from the technical problem was one of the key enablers that made Direct happen! And as it turns out, the recommendation they made doesn’t work very well, and really raises more questions than it answers, and so people are getting scared to experiment… uh oh.

The same pattern is playing out in a bunch of initiatives --- there are now more “health challenges” than I can count or keep track of, we’re clearly stuck on MU stage 2, and (in my opinion) the S&I Framework initiative has taken on too many projects for industry volunteers to sustain. Excepting folks that deal only in policy issues, the consistent message I hear now is “stop the world --- I want to get off.”

What we need now is time for the system to work, partnerships to form, software to be upgraded in production systems, ideas to be tested, consumers to choose what to buy and what not to buy.

I’m not asking for the pace of innovation to slow down --- capitalism takes care of that just fine (even in healthcare, when the conditions are right). I’m asking for the government to slow down … recognize that ONC has found an incredible recipe to guide progress, but that it will only keep working if used strategically.

When you see a funk, take action as you did with Direct. But when things are moving --- monitor and evangelize --- don’t overstep. It’s a tough balance, and I don’t claim to know exactly how to manage it better than anybody else. But I am in the trenches enough to know when it’s working and when it isn’t … and right now we’re on the edge.

ONC, you’ve done great … as a citizen and as a vendor I’m really thankful. Now it’s time to step back for awhile and be national cheerleaders for what you’ve set in motion. We’re getting there!