Becoming the ONC’s CHIO: My Introduction to the Federal Government

I have now been a Federal Employee for a couple of months, the first time since I mustered out of the Army in 1983.  Having spent all of my professional life in areas other than the federal government, I had previously viewed government’s work with suspicion and skepticism.

The challenges I faced as my career shifted, from direct patient care to the corporate environment, required that I adapt and shift focus.  The broader perspectives that I developed supplanted the “us versus them” view I once held and helped me better understand the value of the new HHS initiatives to use health IT to support better care, smarter spending, and healthier people. So when the opportunity to bring my experiences to the federal government arose, I jumped at the chance.

Becoming an early adopter

I was an early adopter of health IT and used an early version EMR in my office.  I thought I was pretty smart – smart enough to re-do all of the “canned templates” that came with the system.  Turns out, though, I was guilty of what I now see many others doing:  trying to modify the system to do something it was not designed to do.  I ended up scrapping my “custom” templates and used the standard ones.  I learned a lot from the experience, and my own mistakes (hint:  validate that the backups actually work before you update the system). But, by using an EMR, my practice was able to better coordinate patient care. One of the real benefits I found was the ability to view notes from the midwives anywhere, anytime, through remote access.  I also discovered, thanks to the EMR, why a few of my patients were not responding to treatment:  an obscure drug-to-drug interaction reduced the efficacy of the primary medication being used.

Developer insights

After leaving clinical practice, I worked with several EHR developers and had my first run in with programmers.  After trying to use the technology they had created, I asked “what were you thinking?” only to learn that a clinician had not been part of the front-end development. No wonder it was clunky!

One challenge I learned from this experience results from developers crafting a system to do something in one way, but when that same system is implemented, it fails to deliver a key functionality.  For example, the CCDA export can generate a nice summary of care to share with the patient, but if implementation does not take into account the intended recipient(s), formatting may suffer, and usability does too.  Same issue arises with a Transitions of Care (TOC) document because different specialties want to see different things.  The fact that the data is there does not mean it will be filtered and displayed in the way I might want it displayed.  This problem creates more noise than signal.  Helping to move the needle (the right way!) and improving that signal to noise ratio is something I get excited about.

Engaging clinicians in hospital settings

I have been involved in several large EHR roll outs, and I found a wide variance in the engagement of physicians and clinicians during the process.  Sometimes clinicians were excluded “to protect them and save their time.” I think this was a mistake. Any valuable insights they may have had about product selection or configuration were lost forever.

I also found that usability and workflow considerations were second to the “how much does it cost” question, despite that the lost productivity from  staff was ultimately going to cost way more than the difference in the price of the EHR.  Nor was the not insignificant unhappiness of non-employed physicians who also had to use the EHR even considered.

There was also another lost opportunity: that as clinicians fiddled with the new systems they might just stumble upon new ways to deliver care more efficiently (the old adage “necessity is the mother of invention” comes to mind). Without clinician input up front, I found that data was often unable to flow between providers to the benefit of patients.

These experiences all contributed to my current perspective.  I see great potential for improving health and health care delivery, but am acutely aware of the challenges and hurdles that must be cleared to deliver on the promises of healthier patients and more productive doctors.  Last time I looked, we have a way to go on both counts.

Joining ONC

And that leads me to why I am excited to be ONC’s first Chief Health Information Officer.  This office is filled with truly brilliant people, with good hearts and heaps of motivation to help move the country forward to help achieve better care for all individuals, smarter spending of our health dollars, and, ultimately, healthier people.  I bring to ONC my experience as a solo practitioner, combined with my work in small hospitals and big integrated health systems.  I have also worked with vendors and developers and as a consultant.  These experiences contribute to a truly balanced view that will help ALL of the parties at the table move down the road to interoperability and I am hopeful that I can help facilitate this collaboration!

In my role as CHIO, I have been following and listening to the industry and see the challenges that are still ahead of us. Despite the significant challenges, I am excited about the many successes.

I intend to do all I can to bring my practical experience and perspective to ONC.  I welcome your feedback and hope we can engage in conversations about what is right, and wrong, with our approaches.  Please consider what I believe is the paramount goal:  to do what is right for the patient. I am unconcerned about doing something for a particular group if it is contrary to that goal.

My hope, my goal, is that we can effectively, as informaticians in a data-driven community; help lift everyone up to the level that is required to deliver the learning health system of the future.


  1. Dr.Sara Guido says:

    Consider engaging Nurses in creating EMR’s. The Registered Nurse, knows best how to capture the care she delivers in a clinical setting. Goes for PT, MSW, PhD etc.
    it’s a joke that IT folks who aren’t clinicians create EMR.
    It’s getting better, but save time, go to the experts who know what needs to be documented.

  2. MB says:

    I feel kinda sorry for you Dr McCoy. You are entering a strange world at ONC. They do not share you practicality and front line clinical experience that your have or they have simply forgotten. You will be in for a rude awakening. First, CMS and ONC is hell bent on MU and certification of EHR. And both of those things are the LAST thing any front line provider or non-big 3 EHR vendor wants. The biggest problem facing EPs today is EHRs that we want usable, efficient, safe and secure systems. We have none of those now. If we ask our EHR vendors for a custom workflow, that cannot be done because it will affect certification and that means no MU dollars and risking decertification. We have built a MU system and vendor system to try to achieve a one size fits none and loads of “objectives” with 20 + measures in them that make no sense for at least half of the front line EPs out there. As an orthopaedic surgeon, I do NOT need NOR want a TOC or CCDA on every patient. I do wish to be able to reach out to an HIE to retrieve images or reports but not EVERY single thing, just what I want. But that does NOT exist today. Also when you read Stage3 MU you see where they are headed….the above TOC and CCDA firehose data disaster, 25% VDT from our portal? That is absolutely insane, Public immunization reporting? for Ortho? Again, ridiculous. All these ridiculous attesting, numbers numerators, denominators, auditing, its insane. That is why you will see a stampede away from MU and EHR and Health IT. Its really time to let the EHR market work for EPs and not MU and ONC. We want our vendors asking us what we need and want, not some clunky disaster to meet MU. Then when you pile on CQM, PQRS, VBM, MIPS, ICD-10, HIPAA, MOC etc etc etc. we are literally at a breaking point. I think the crashing of the Stage 2 numbers should be a very serious sign that the program is failing and failing fast. But I guarantee that NO ONE will be honest about those numbers and try to play up any other numbers to show success. ONC has a very serious problem with criticizing itself. They have a HUGE problem with puffery language with buzzwords thrown around, and a ton of backslapping and never a critical look at the street level disaster that is occurring. Again, good luck, but you may be in for a huge shock, as ONC will think they know better than anyone what EVERY EP needs from an EHR, and they actually don’t and never will.

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