Sunday, June 14, 2015

CODA: the back story, Part 4

By mid-April, with responses to the call to action about the Roadmap's governance Calls to Action taking up an increasing proportion of my time, I had a choice to make.  I could either renew a contract to support ONC's work with SIM grantees and other states implementing delivery system reform while trying to do the governance response coordination as "a hobby," or I could step away.

It so happened that the end of the contract/opportunity to renew fell on days (April 21-22. 2015) that I was speaking to a National Governor's Association convening of state health policy leadership. Their sense of urgency and motivation was palpable.  Their bosses, the governors, wanted to know why they were still waiting: why after all the time and money invested, the promise of HIT still eludes us.

Simply put, like lots of leaders in America in 2015, governors can't understand why they don't have better instrumentation to monitor and manage what is, for most of them, one of the top three spends for state government, between Medicaid, state and other public employees, and retiree health plan costs.

That sense of urgency, coupled with motivation (aka "a bias for action"), came together with a third element that made me strongly suspect that this could really be the time for success. The state leaders expressed it, and I've heard it echoed in many other settings. People have come to realize that this stuff, getting HIT-HIE to work correctly, is a huge, huge undertaking, too big to be done alone. A willingness, even a desire, to collaborate is that third critical success factor.

With that inspiration, knowing that there is a broad and growing cadre of people who want to work together on solutions, I stepped away from ONC.

Email to ONC staff, April 23, 2015:
Subject: a somewhat abrupt but nonetheless appropriate change


In retrospect, it was only a matter of time, but it's come together more rapidly than anticipated. It's time for me to step back "outside." I’ve worked with many of you, in several roles, long before I came to ONC and hope I’ll have a continuing, positive relationship with you long into the future. For all of its vast complexity, the world of HIT is a small community. ONC is the heart and center of that community.

It has been a profound pleasure to spend the last two+ years -- first there with you, in-residence, and then remotely, on contract -- “behind the curtain” at ONC and HHS. You all are a remarkable, talented, dedicated crew, doing critically important work, and doing it with great zest and cheer. It has been a whole lot of fun to be part of the ONC team, and a great honor to represent ONC in many conversations with state colleagues and others over that time.

I won’t say “I am going to miss you” because I’m not really “going” far, just shifting roles. Many of you know my story of asking Dr. Blumenthal early in his tenure, and Farzad, already on-board as Deputy, back in 2009, what their vision was for HIE. “What’s the roadmap?” Their answers were not good, and I remained a bit of a squeaky wheel on that subject. As such, I greeted publication of the draft Nationwide Interoperability Roadmap v1.0 with joy. It is that happiness that propels me to a new role, working to ensure that its invitation and possibility is embraced -- and acted upon -- as broadly as possible.

In recent weeks, in my off hours, not representing ONC, I’ve had conversations with colleagues in states, at HIEs, in the science and research, public health, and human services communities, the payer and purchaser community, and others working on delivery system reform. It was a kind of exhortation, a call to action about the Roadmap’s Calls to Action, particularly the calls to action on the interdependencies of governance.

My view is that governance will be modular, following the distributed infrastructure of the ecosystem itself.  That governance infrastructure will function best, with a focus on access and equity for all, if it reflects the interests of all of the occupants of the learning health system (e.g., all of us) and the different players, organizations, and interests working to construct and operate the learning health system and implement delivery system transformation. The responses to the exhortation indicate that I’m not alone in that view.

To my surprise but also delight, what began as an “after hours advocacy hobby” has grown into something far too important to work on in my spare time. I felt it would be irresponsible to not at least take a shot at engaging folks in a conversation, given that we finally have a Roadmap. I had no idea the response would be so substantial and substantive. To ensure that there is no confusion about my role going forward, I have withdrawn from my role on the SME Team for the HIT Resource Center and support to the OCT. Tuesday was my last day on contract.

We have a challenge: governance of interoperability is as vastly complex as the ecosystem itself. Governance will take the proverbial “village” and while there is without question a role for government (federal and state) in governance, the scope and scale of the learning health system (and the incremental steps we take toward it along the way), mean that government is a necessary -- even essential -- but not sufficient partner in this work.

Some in the community favor a "Wifi Alliance" solution to governance, but that will inevitably be far too narrow in scope. Interoperability must be governed with a commitment to open and unbiased exchange, organized and operated for the public good.  As I see it, the Roadmap presents an invitation: create a vendor-, payer-, and institution-agnostic governance process for the interoperable critical infrastructure of the national health, healthcare, research, and human services information supply chain. Given the substantial alignment among a broad and growing community of players interested in responding to that invitation, I am going to now focus my time on seeing how a broad set of stakeholders--state and federal, public and private--can come together for mission-critical collaboration for HIT. I welcome your thoughts and ideas about who should be included and what that should look like, and hope we can work together to instantiate a durable public-private collaboration to shepherd and coordinate the governance conversation moving forward.

I continue to draw guidance and inspiration from Karen’s points in her closing remarks at HIMSS. We are indeed in the fourth quarter, and this is a moment to “leave it all on the field” in pursuit of interoperability’s success. As such, I look forward to what I hope will be a continued productive, fruitful and collaborative relationship with you all in the future.

Best wishes,

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