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Arrival of new HHS healthcare tech boss could augur big changes at ONC

President Trump's appointment of former GOP congressman John Fleming, M.D., to a newly created health technology post could portend ONC downsizing and MACRA changes.

The new HHS healthcare technology top official's plans are still unknown, but signs point to possible changes to ONC that could weaken the agency's regulatory authority.

After President Donald Trump installed John Fleming, a former Republican congressman of Louisiana, in the newly created post of Department of Health and Human Services (HHS) deputy assistant secretary for health technology reform, Fleming told Politico he thought he had been interviewing for the top Office of the National Coordinator for Health IT (ONC) job.

Not so, it turned out. But the new HHS healthcare technology chief -- a longtime associate of Tom Price, the current HHS secretary and a fellow physician and former GOP congressman -- nonetheless also mentioned to the Washington, D.C., website that ONC "may be reorganizing."

John Fleming, former Republican congressman of LouisianaJohn Fleming

Few in the capitol, other than his fans, want to comment publicly about what Fleming's ascension to the top HHS healthcare technology post could mean for ONC.

HHS, for example, ignored a SearchHealthIT request to provide a job description for Fleming. And HHS still has not issued a formal statement about Fleming's appointment.

And Fleming, who served four terms in the House before losing in a Republican primary for Senate in Louisiana last year, has remained publicly silent since he took the HHS healthcare job on March 21.

But in Fleming's congressional record, there are more than a few clues as to what could transpire. And there are some other circumstantial signals.

Does ONC face downsizing?

Perhaps the biggest puzzle: Since there has never been an HHS post with Fleming's title, the development presumably could mean that ONC would not get a national coordinator at all, and the whole agency would just be folded more tightly into HHS.

President Trump installed John Fleming a former Republican congressman, in the newly created post of HHS assistant deputy secretary for health technology.

The top ONC position, after remaining vacant for more than two months, has been filled with the apparent appointment of Donald Rucker, M.D., former Siemens chief medical officer.

In the worst-case scenario for people who like ONC, the already smallish agency could be downsized. A cautionary footnote to that view is ONC was created by a Republican president, George W. Bush.

Along with administering the technology end of federal healthcare reimbursement programs, ONC promotes interoperability; patient access to health data; and newer technologies and approaches, such as open APIs, blockchain and telemedicine.

Of course, if ONC is trimmed back, that would please conservative health IT constituencies and groups such as Health IT Now.

Health IT Now released a fairly glowing statement on Fleming's appointment. The biggest health IT organization, the Healthcare Information and Management Systems Society, also praised Fleming and called him an advocate for technology in healthcare, while decreasing unnecessary burdens on providers.

A week earlier, Health IT Now wrote a detailed letter to Price calling on HHS to review the role of ONC, asserting that ONC has overstepped its regulatory authority.

Health IT Now was specifically referring to ONC's health IT certification program, in which vendors submit their software for testing by ONC-contracted labs to see if it meets interoperability, usability and other measures to qualify their systems to be used for Medicare and Medicaid reimbursement.

Vendors have long complained about the program. Trump campaigned as antiregulatory. Fleming, although he has said he is pro-technology and EHRs, could well trim, or even eliminate, the certification process as being overly regulatory.

ONC budget seems to remain solid

All that said, the outlook for ONC may be less dire than some pro-ONC people fear.

For one, the agency's $60 million line item in the federal budget remained untouched in Trump's budget proposal for 2018. Indeed, the budget doesn't even mention ONC, so that could be good or bad for the agency.

Also, the landmark 21st Century Cures Act of 2015 specifically lays out health IT provisions that are now the purview of ONC, including encouraging interoperability and preventing information blocking.

Moreover, cutting back ONC's role or significantly weakening MACRA reporting would most likely entail removing statutory language in measures such as the HITECH Act of 2009.

That could prove contentious in Congress, where issues like value-based care and interoperability have had broad bipartisan support.

Meanwhile, in Congress, Fleming, a family medicine doctor and addiction specialist, did a stint as co-chairman of the GOP "Doc Caucus," which could be seen as the legislative voice of the beleaguered solo doctor frustrated by EHRs and government reporting mandates.

Fleming supported a proposal to delay meaningful use stage 3, and in his capacity as a Doc Caucus leader, he criticized MACRA as too complex and its reporting requirements too burdensome on doctors.

Fleming also co-sponsored several bills to repeal the Affordable Care Act.

Stay tuned for how he and Price will define the government's role in health IT.

Next Steps

Amid change of administrations, ONC active at HIMSS

MACRA could be tough to handle for small physician practices

ONC determines interoperability measures for MACRA

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Should ONC stay in the health IT certification business and why?
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This article is OK, as far as it goes. But it fails to address real issues facing both the Fed Government role in tech and facing us in the real world who have to live with the Fed’s role in tech.

Technology moves very fast. Government bureaucracies, especially Federal bureaucracies, move very slowly.

No criticism of any one person or political faction, the bureaucratic approach has a significant downside.

Government bureaucrats seem to have no clue how to normalize their own roles in the real world.

Historically the government has always had a role in defining “weights and measures”. It defines what the length of a yard is, and what the length of a meter is. But historically, the government never told a carpenter whether to use the English-American measurement system or the Metric system. The carpenter had freedom to choose.

Government tech bureaucracies, and especially ONC have extremely fuzzy thinking and do not normalize the definitions of measures separate from mandating the use of those measures. They assume that the only reason to define a measure is to mandate.  Maybe that is a little extreme. But that is the way it feels in the real world.

Forrester, Gartner and groups like them do a far superior job to the ONC or any government bureaucracy in rating and ranking technology in terms of usability in the real world. If the government got out of mandating the usage of specific measures and just defined those measures, then the Gartners of the world would grow in influence.

As Alexis DeTouqeville wrote in Democracy in America, the genius of America is in the interlocking set of voluntary controls on behavior through overlapping voluntary institutions that set standards for behavior.

Writing requirements for a data warehouse to meet already obsolete government mandates when you know that the data warehouse won’t even be built for years to come due to the slow pace of the bureaucracy does not make for good delivery of Medicaid. It is a dis-service to both the taxpayers and the Medicaid constituency.

LBJ had whiz kids running the wars on Vietnam and the poor. These whiz kids thought that if the government could hire the best and the brightest then government would solve everything. When government did not solve everything it was blamed on not having enough information. (If I knew then what I know now). Now with Big Data and fast hardware these same people have the delusion that they will now be able to achieve where the whiz kids failed.

New fast technology is a tool. I am all for it. It is my life. But it is just a tool. It can be used for good or for evil, and competently or incompetently. There are plenty of examples of hackers who use it for evil. There are also plenty of examples of incompetent Big Data companies using big data incompetently to come to the wrong conclusions that may be just as dangerous to society as the evil ones. Indeed some would say that the arrogance of the delusional Big Data evangelists is as evil as that of the hackers.

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