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

In the second part of a two-part interview, departing National Coordinator for Health IT Farzad Mostashari, MD, discusses EHRs and quality measures, Regional Extension Centers, and VDT requirements.

In the second half of my exit interview with outgoing National Coordinator Farzad Mostashari, MD, of the federal Office of the National Coordinator, we discussed the evolution of electronic health record systems and concerns over quality measures. Part I of the interview is here.

HLM: Some argue that HITECH has funded the purchase of EHR software which is really not suited to the emerging value-based care system, that today's EHRs are overwhelmingly designed for fee-for-service and maximization of revenue.

Mostashari: I would say that their views are exactly correct, but a little outdated. When I testified before Congress seven years ago, that's what I said, and I said that EHRs today don't let you make a list. They don't let you measure quality. They don't collect smoking status, or blood pressure, in standardized ways. They don't offer decision support.

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One EHR vendor's chief technology officer, during their acquisition process, said, 'we don't believe in decision support.' That's what they were focused on, and that was the whole point of Congress saying, we're not going to just pay for systems. We're going to pay for systems that have what it takes to improve care, and their use of it that way.

So when we see outpatient providers' ability to look at evidence-based guidelines, increasing within a two-year time period from 20-some percent to 50-some percent… that tells you something... That's data.

That's evidence that says that EHRs are changing, and they're use is changing, because of the Meaningful Use incentive program. So I guess I would say EHRs are critical tools… and we can't afford to not use them as tools for population health management and consistent application of guidelines and care coordination and patient engagement.

It would be a tremendous loss if we just view EHRs as data-harvesting machines sitting on top of an army of data slaves, tapping away. That's not the vision that I have for electronic health records.

HLM:Jeff Immelt, the CEO of GE was quoted recently as saying he had never seen an industry with so many measures that didn't matter. That gets to my question of quality measures. People are complaining, even in Congress, that there are too many of them. How do you respond to those concerns?

Mostashari: Patrick Conway and Carolyn Clancy and I wrote an article in JAMA which talked about, [and] I hope, laid out that vision for where we need to go in quality measurement. I would agree that there are a lot of legacy measures that don't really matter that much.

Part of what we laid out in the paper is [that] we need to move towards measures that matter, towards measures that are more for accountability purposes, more outcomes-oriented, and more parsimonious, more broad-based and parsimonious.

So if we have a thousand measures, [and] they're all about clinical processes for each different specialty, a chicken in every pot, well that's okay. But we should also have measures that apply to anyone who writes a prescription. A measure around medication safety and safe prescribing would apply to them, and we don't have a very good measure for that.

Anyone who gets a referral or sends a referral should be judged on the basis of how well they close that loop. And there were no measures for closing the referral loop until we worked with CMS to develop them for Stage 2 of Meaningful Use.

I mentioned medication safety. There was exactly one measure. I wouldn't say we had too many measures for medication safety. There was exactly one measure for safe prescribing. It was safe prescribing in the elderly, and there was a list of 100-plus medications that quote unquote elderly patients shouldn't be prescribed.

Unfortunately, it only accounted for three percent of medication errors that led elderly patients to the emergency room. What accounted for 40 percent was Cumadin, Warfarin, and keeping people in the right therapeutic range for Cumadin, so they don't bleed out.

Was there a measure for that? Not until Stage 2 Meaningful Use, where we worked with CMS to develop one for that. So I guess I would say it's a little more complicated than that. We need measures that matter. We need to make measures in which the data for it from… routine care provisions, so we reduce the burden of it. And [we need to make measures] that are meaningful, that are longitudinal outcome-based measures that make use of the strength of electronic health records, and we are very much making progress on doing that.

What I think we need now is for big employers like GE to demand of their health plans that they all use the same damn measures, instead of providers getting 12 different signals from 12 different health plans, so that I think is another area we highlight in the paper as needed focus for quality measurements.

HLM: Touché. Is any of the pause in healthcare spending growth attributable to the role of technology?

Mostashari: We don't know, and I don't think that the role of technology in reducing the growth in healthcare spending is going to be something neatly attributable. It's going to be part of a broader system of changes in how we pay for and deliver care, for which health IT is an essential component, but not by itself able to be attributed to some portion of it.

So some portion of this is due to readmission adjustments, and the decline that we're seeing in readmissions. Has health IT contributed to that? Probably. I think it probably has contributed to that.

Certainly if you talk to hospitals that are reducing their readmissions, some part of it has to do with better communications and better adherence to standardized protocols. If you talk to any accountable care organization, in particular the folks who are successful or trending toward success on reducing costs, and you ask them, do you need health IT to do this? They'll say obviously we need health IT to do this.

It starts with being able to make a list of patients, and you can't do that on paper. So I guess I would say it's a little more complicated than that. But I do think that if we want to get to better care at lower cost, not just less care at lower cost, less care at lower cost, that we can do.

In fact, we tried that, right? People didn't like it very much. What we're trying to do now is better care, better health at lower cost, and that means that we have to think differently, and we have to use every tool at our disposal, in particular information tools, and in particular the patients, and empower the patients. So those all, I believe, are going to be fundamentally enabled by the technology that we're laying the foundations for.

HLM: As part of your HIE roadmap, you urged that funding be extended for the Regional Extension Centers. Where is that funding going to come from?

Mostashari: We didn't propose an existing vehicle for that, but I think the issue is, are the extension centers adding value? Are they adding value to states? In which case I would hope that states would support them.

There's actually [a] 90/10 federal match available for states who wish, like Kentucky, to support the extension centers. I would ask [whether there is] value being provided to specialists and others who would get consulting practices for something like $5,000.

I don't know where you can get a consultant to come to your practice for $5,000, but if you think that's valuable, then I would hope that they would provide funding to the Regional Extension Centers. And I would hope that if the federal government is able to, and this brings us back to a little bit of our budget discussions, then I believe that it's been a very sound investment of public funds, and it would be, I think, terrific if there was continued support for extension centers beyond Stage 1.

HLM: I've heard many providers are scrambling to meet the "view, download, and transmit" requirement in Stage 2, some going so far as planning to put PCs in the lobbies of their hospitals, so patients will be encouraged to log in there. Other people complain they're in rural districts which have very poor broadband support.

Mostashari: I was just at a roundtable yesterday, and one of the providers was saying, "I can't imagine how we're going to do VDT." The other provider said, "Oh yeah, we met that, no problem. That's easy." And I said, well what do you mean it's easy? What did you do? And she said, "Oh, it's just workflows. We just tell patients, for example, that if they want to talk to us, the best way to do it instead of trying to leave a message is to message us on the portals. We said, if you want to get your lab values, go to the portal. We say, if you want to get your summary from this visit, go to the portal. And we make sure they have their user ID and their password when they leave. And that works." So it's all a question of implementation and workflows.