Skip to main content

Farzad Mostashari Looks Back as He Steps Down

 |  By smace@healthleadersmedia.com  
   September 24, 2013

The departing National Coordinator for Health IT reflects on the effect of the sequester, says meaningful use Stage 2 is a done deal, and lauds the free market for EHRs.

Last week I held a final conversation with Farzad Mostashari, MD, before his tenure as National Coordinator for Health Information Technology in the federal Office of the National Coordinator (ONC) ends. In two years as the nation's health IT czar, Mostashari has become the face of meaningful use and an advocate for health information exchange. Here is part one of our conversation.



Farzad Mostashari, MD, ScM
National Coordinator for Health Information Technology

HealthLeaders: Everybody says you're a hard act to follow. Is there any news on that front?

Mostashari: National search…as has been said, we've had the right national coordinator for the right time, and I have a lot of faith in that.

HealthLeaders: What do you think has been your greatest achievement during your time as the head of ONC?


See Also: Q&A: Mostashari Reflects as He Prepares to Exit ONC


Mostashari: I guess I would defer a little bit the idea that there's really any individual achievement in this whole thing, because the national coordinator doesn't do anything by themselves. It's 170 people here, and it's tens of thousands of people in the community to whom any achievements really belong. For myself, I think one thing I did, just from my perspective coming into this, was to focus on the outcomes in terms of population health. I think I brought a little more of an appreciation of that to the community, and also thinking about what we're going to need to do around chronic disease management and prevention for populations.

Then the other thing that maybe was a little surprise to myself was the pivot that we did to expand what we focus on to include consumer e-health and personally controlled health records. Those are two things that I may have nudged the direction a little bit more than where we were already going.

HealthLeaders: How about the biggest disappointment in those four years?

Mostashari: In the movement as a whole, what gives me a little pang every time…is when people say, We don't understand how the stuff you're doing on health IT fits into everything else that's going on around accountable care and new payment and delivery models, and how do these things fit together. I feel like, gosh, I failed, in that this is on me as kind of the communicator for ONC, in terms of having failed to make that connection more clear, because it is absolutely what we're trying to do.

All the discussions have been working backwards from those goals around care coordination, population health, and making sure that people have the tools to do that, and they really do fit together pretty well, but if there's something that kind of pains me is when people still don't see the connections.

HealthLeaders: A lot of people are asking for your advice for the next coordinator. I want to focus on two particular pain points. One is the possibility of a government shutdown and how that would impact the office. The other is just the continuing heartburn that the sequester has caused.

Mostashari: What can I say? I took over as national coordinator on April 8, 2011. It was the day the government was supposed to shut down. So my first act was to assemble all the folks at ONC and talk about the fact that they may need to go home, leave your Blackberrys, and you're not going to get paid until we don't know when. That did not come to pass. We have limped through with continuing resolutions and then sequester cuts without really an ability for the department to rebalance how we budget. Things are frozen at the same relative proportions between initiatives for years. That's like passing a household budget where your kid's in school now, but you still have to keep your budget for diapers. You can't increase your budget for school supplies. It's crazy. But despite that, what I would say to the next national coordinator on that is to lean on the community, and to tap into the desire that everybody has to help us succeed.

Beyond anything else, I think that's been such a gift for us at ONC—the willingness of people in the community to pitch in, to do pilots, to do implementation, to contribute their comments, to make it smarter, to pitch in and participate. But this is hard. Leading a federal agency like this is hard, and that's something that I'm sure the next national coordinator is going to be well aware of.

HealthLeaders: ONC and CMS recently put forth their roadmap for making health information exchange the norm rather than the exception. What additional regulation or legislation do you think will be required to get to that point, beyond what you've already announced?

Mostashari: I don't know. It's going to be something where we continue to have the roadmap. We know where we're going. We know what the leaders are. We know what our immediate steps are. And we know what the destination is, and we have such a rapidly changing and dynamic field, both in terms of the technology, in terms of policy, and in terms of payments and market forces, that we have to remain agile, and have the ability to assess what's happening and react. So I think where we are right now is the best balance that we've been able to craft in terms of permitting for innovation and flexibility, while providing guidance where there's low regret that that's going to freeze things. But that may change, and if it does, we have to be prepared to act.

HealthLeaders: There's been a chorus of calls for longer timeframes for meaningful use Stage 2, but you have hung tough. What are your thoughts on that decision and all of the outcry about it?

Mostashari: I think we've gotten credit for really, seriously, actively soliciting and actively listening and engaging with the field. So yeah, have we heard providers and hospitals and vendors say…and the associations, 'Yeah, it would be good to have more time'? Yeah, we've heard that, and we understand about the pressures that folks are under, and the speed with which change is happening, and the competing priorities. On the other hand, we also appreciate the calls of the other side, from vendors who say 'No, we're ready. We worked hard to be ready. We see that as our competitive advantage. Don't slow down.' From providers who say, 'We're ready to go,' and from groups like payers and health plans and purchasers and consumers and others who say, 'We can't wait for the benefits.' But ultimately, it's not about stakeholders finding a metric mean.

Good policymaking is about finding what's in the public interest, as you incorporate all of the information you get. It continues to be my belief that we can talk about Stage 3 but Stage 2 rulemaking is done. We already extended Stage 2 by a year, and then by another nine months, and we have a final rule. It is my belief that people need to get with the program on that, and we'll have another round of rulemaking about the timing for Stage 3.…[For] those people who need most to get moving and not hope for delays, hope is not a strategy, and they need to act now. It's getting late, and they need to get a move-on.

HealthLeaders: Do you have any sense of how many vendors who qualified for Stage 1 may not make the cut for the Stage 2 certification?

Mostashari: What I do know is that two-thirds of the market has already certified for Stage 2, by which I mean if you look at the market share, those vendors that account for two-thirds of the existing attestations have already certified, and there are more in the pipeline, so that's going to be something that we continue to watch. We continue to expect that the market pressures will have vendors put the necessary resources into it; there's a lot of revenue coming into vendors, and if they need to prioritize resources into getting the development dollars and the implementation dollars into place, then I would expect the market to reward those who do that, and to punish those who don't do that. That's the way markets work, or at least are supposed to work.

The other issue is, why exactly does it take so long for some vendors, not others, in terms of how long their development and implementation cycles are? Again, we've looked at some of our processes, and we've reduced the timelines for quality measure development, for our regulatory processes. We've reduced the timeline and cycle times for standards acceleration and endorsement, and I would expect that industry should also look to see what they can do to reduce their cycle time, which includes some of the legacy vendors.

HealthLeaders: Have you been concerned about reports of lots of rip-and-replace of EHRs? Some of it has been attributed to a provider that bought a product maybe for Stage 1, but found that product was inadequate to cover what Stage 2 demands.

Mostashari: Stage 2 is more demanding. It's supposed to be more demanding. I guess I'm of two minds. If there is replacement happening because providers are changing their affiliations and there's been mergers or acquisitions, that's understandable, and there's a lot of that going on, and there are reasons for people to want to be on a single system. There may also be good reasons why someone might say, 'I like that better, and I'm not locked in to a single vendor.' Markets work well when you get to choose one, but then you're not stuck with a vendor for the rest of your life. Good markets exhibit switching behavior, and if there are vendors who are more agile, more responsive, better customer service, better usability, that people want to switch to, then the overall quality of the marketplace will improve, and innovation will be rewarded.

That's a good thing. If, on the other hand, people are left high and dry because there are poor business practices, if someone is a perfectly good vendor that people like that is bought out and that product discontinued to force people to switch over to another market, then that is less good for the overall benefit. I would say this is another one of those where we have to really observe and understand what's happening, not only [with] the only remedy being to slow down, but think about how the market participants, including importantly the customers, can exert their influence on creating a more perfect market.

Next week, the second half of my conversation with Mostashari: too many quality measures, how much credit IT should get for lowering costs, and whether today's EHR software is outdated.

Pages

Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.

Tagged Under:


Get the latest on healthcare leadership in your inbox.