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'Exit interview' with outgoing HIT coordinator Farzad Mostashari, M.D.

The outgoing national coordinator for health IT addresses a few touchy subjects and talks about his next act.

The Office of the National Coordinator for Health IT (ONC) offered us one last interview with its leader, Farzad Mostashari, M.D., on the first day of National Health IT Week in Washington, D.C. We took the opportunity to empty our desk drawer of a couple of nagging questions, as well as to look to the future.

What are you most excited about hearing this morning at the Consumer Health IT Summit, which brought patients, providers, venture capitalists and federal agencies together to update us on patient engagement efforts and exchange ideas on furthering them?

Farzad Mostashari: I can't wait to see what happens in the next 12 months. The question for us here today is, 'Is now the time? Is it time yet?' because every time we've had these [patient engagement conferences], there's been a sense that we're not ready: Providers aren't ready. Patients aren't ready. The technology's not ready. The business case isn't there.

All the barriers that have held up this real shift in engaging patients as partners and empowering them -- this could be it. This could be the time. The next 12 months could finally be the time when the pieces come together enough for this -- as [U.S. Chief Technology Officer] Todd [Park] said -- ecosystem to establish itself. And like any ecosystem, you can't just move one lever; you have to move multiple levers simultaneously to create micro-environments where everything makes sense. Financial incentives need to be aligned toward engaging patients, toward working with them for better health, toward being open to them as partners and open to their family members because it makes business sense. Because you're going to be judged on quality outcome scores or patient experience scores [and other measurable health metrics, such as medication adherence or motivating patients to exercise].

By law, ONC can't even look into the feasibility of a national patient identifier. I know ONC announced a patient-matching initiative last week, which tackles the problem from a different angle. Health system CIOs I interview are demanding the national identifier to keep their patients' data with them when they move from one facility to another. Those CIOs, under the auspices of the College of Healthcare Information Management Executives, will take their case to the Hill this week. What advice would you give them to persuade Congress to overturn its ban on a national patient ID system?

If people are documenting things they didn't do, that's a) fraud and b) really bad patient care. So we're going to come down like a ton of bricks on that.
Farzad Mostashari, M.D.,national coordinator for health IT

Mostashari: I think it would take the CIOs to show that they have squeezed all the juice out of the existing ways they have of matching patients before they ask for a national patient ID. Let me ask you, for Medicare beneficiaries who all have a unique patient ID -- their Medicare ID number -- how well are we doing with patient matching for those patients with reducing error rates and duplicate records and wrong records for those patients? How well are we doing in terms of completeness of the information on the attributes like address? Are we verifying them with the Postal Service? Are we verifying the Social Security number? Using other forms of identifiers like cell phone numbers? There are patients dying today because we don't have good processes in place for getting complete information, good identification, not creating duplicate records in the front end of the healthcare process.

How well are we using existing attributes that we have before saying, "We can't do anything; let's wait for another attribute to come and save us?" That's what it's going to take. That's what our patient-matching initiative is focused on: how to get the most value from the attributes that can be used today. That's what the CIOs need to do before their voice will be heard -- that's my advice to CIOs.

Epic Systems Corp. CEO Judy Faulkner is active on the HIT Policy Committee. CIOs complain frequently to us that the Epic EHR is a roadblock to interoperability with other vendor EHRs, even under their own roofs. You yourself speak out against "walled gardens" of patient information, where noninteroperable systems prevent patients from choosing which providers they can see. People email me all the time with conspiracy theories explaining this disconnect. How does her voice fit in with federal HIT policy?

Mostashari: There are two different issues you raised. First, the members of the Policy Committee: They come from diverse perspectives, and each of them -- whether they're appointed by the Government Accountability Office, the House and Senate majority or minority leaders, or by the [HHS] secretary -- they each have an obligation and a duty to represent not their company, not their organization, but to represent the perspectives of a group to work toward reaching a consensus for the public benefit. I believe that all members of our Health IT Policy Committee have acted in that way. What makes this work is people not representing the parochial interests of their individual companies they come from, but thinking of the public benefit and thinking about the perspective of the class of the organizations they're with: researchers, public health advocates, consumer representatives, healthcare providers or others. I don't think there's been any evidence that would imply that any of the Policy Committee members have not acted in good faith.

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The second issue is a more general one: How do we make sure that vendors listen to their customers and promote what is best for the public good through the use of these investments that the government and the taxpayer are making? Is the market demanding interoperability? Five years ago, the answer was no. Today the answer is yes. The fact that we're hearing this so much from healthcare providers, I think, is a positive sign. [They realize] that having their own walled gardens is not a long-term, viable strategy. Another issue is whether vendors are acting in ways that inappropriately restrict the flow of information. The big picture of what I'm seeing is that some of those perceptions are a little outdated now; we're actually seeing an increase in functional interoperability across different vendors and organizations. A lot of it is being promoted by the changes in payment systems.

I will say, though, when the patient says, "Give me my data," and they get their data, they will get it from every system. There is no ability to limit the flow of information to patients from different products. [ONC] certification [standards] and HIPAA work together to ensure that. If there are vendors who are trying to pursue a walled-garden strategy, that wall will be crumbling pretty quickly.

Some people portray EHR systems and meaningful use as government incentives to promote upcoding and fraud. What would you say to these people, some of who clearly are doing it to promote political agendas, and others who might not quite understand how IT infrastructure works?

Mostashari: What we're trying to do is change both the tools and incentives for those tools to promote overall health and care coordination, rather than having EHRs be what they were when I first started looking at them for purchase almost a decade ago -- billing and documentation machines. That's what everyone was paying for. That's what meaningful use is changing. The question isn't, "Why is meaningful use doing this?" it's "What was happening before?" Much of the data that has been presented and has been talked about predates the first meaningful use payments.

The whole point of meaningful use is that EHRs shouldn't just be about billing and documentation; they should be about making a list of [patients, looking at quality, providing safer care, engaging the patient more and coordinating care better]. That's what meaningful use and the [ONC] certification criteria are focused on. That's what the new payment models that move beyond "do more, pay more" or "heads and beds." It's all good, it works together, we're creating a new model of delivery and a new model of incentives. Meanwhile, we're still living in a predominantly fee-for-service world, so [something that the ONC] and our colleagues in CMS deal with every day [is] managing payment programs. This is nothing new for them. They are on the alert; they're smart regulators. It's a cat-and-mouse game, and they're the cats. There is nothing that can't be handled -- including overt fraud. If people are documenting things they didn't do, that's a) fraud and b) really bad patient care. So we're going to come down like a ton of bricks on that. EHRs provide auditors and regulators with tools and enforcers that they'd never had before. The real problem people should be focusing on: Why do we have incentives in the system for maximizing documentation versus maximizing health?

Could you tell me about your next act?

Mostashari: I'm going to finish strong in this job. October 5 is my last day, and October 6 I'll take some time off, and then October 7 I'll start making a plan for what's next. What I can say is that it's going to be something around the tools for changing the habits of healthcare to meet the demands of the new payment models -- but also, what patients deserve. That's what I've been passionate about, and I'm sure that I'm going to spend the rest of my life trying to work on that transformation through whatever tools are at my disposal.

Let us know what you think about the story; email Don Fluckinger, news director, or contact @DonFluckinger on Twitter.

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