Mostashari's biggest Meaningful Use regret and health IT's future

As head of the Office of the National Coordinator for Health Information Technology for nearly three years, Farzad Mostashari, MD, focused on making technology accessible and useful to physicians. Now, three years after leaving his post at ONC, many of the same struggles continue to plague medical practices.

Acknowledging that fact, Mostashari remains confident in the power of data to move medical practices forward and improve patient care. 

As part of a wide-ranging interview on healthcare with Medical Economics for our August 25 cover story, Farzad Mostashari, MD, also entertained questions from our readers.

Farzad Mostashari, MD

Mostashari is currently the chief executive officer of Aledade, a company aiding independent primary care physicians in joining accountable care organizations (ACOs).

We asked readers for questions Mostashari could address utilizing his wide-ranging HIT expertise and selected a handful to ask Mostashari. Perhaps not surprisingly, most had to do with the health IT troubles facing physicians today.

Medical Economics: What went wrong with the Meaningful Use program? And what could you have done better during your time at ONC to ensure its success?

Farzad Mostashari: I think [Meaningful Use] became too much about compliance and not enough about outcomes. And when we started Meaningful Use, we had laid out stages one, two and three.

… And we put out the structure where it was like stage one is collect the data. Stage two is do something with it. Stage three is outcomes, so that when you're doing stage one and stage two, you know that you're doing it for a purpose. And the stage three outcome is like “save lives and don't kill people.” And we got a letter from the Federation of American Hospitals that said “that’s double jeopardy.”

[Editor’s note: In a letter to the U.S. Department of Health and Human Services, the FAH claimed that Medicare already had a quality improvement program, and adding new quality improvement targets under Meaningful Use, with the threat of reduced reimbursements, would be the “double jeopardy.”]

… And basically the message we got [from FAH] was, "We're going to sue your butt if you do that." And we backed away from it. In retrospect, I would've said, "Sue me." And I would've kept that tight connection to the outcomes and working backwards from the outcomes.

ME: How do you see IT and Internet applications changing how healthcare is delivered, especially when it comes to communication and sharing information?

FM: Well clearly, they have. For all of its faults, one thing Meaningful Use did accomplish was that we moved off of paper. And as bad as some of the usability issues are with the [electronic health records (EHRs)] today, I don't see people going back to paper. And it is the foundation for doing more things.

So the question is: How does this now become the infrastructure for doing more and in a more “Internet-y” way? The key here is going to be, “Can I use other tools on top of and around and attached to my EHR?” That's really the question. And for that, we need to open up those EHRs to third-party applications. The technology part of that is important-and there's good progress made on that with what are called application programing interfaces, [APIs,] and FHIR (Fast Healthcare Interoperability Resources), and all that kind of stuff.

But more important than that are actually the business agreements. So again, when you're signing a contract, make sure that you know what your rights are to use your own data with another application and your rights to get your own data out … I think that's going to be the key.

ME: What are the effects on a practice and patients when an EHR company closes and its system is removed from use?

FM: One of the really worrisome things has been when practices couldn't get their own data in that situation, or the situation where a billing dispute [arises, or even where] a provider dies and the Office of Civil Rights that manages HIPAA actually is very aggressive about making sure that there's no loss of continuity in those situations. So practices should always be able to get their own data out of those systems, whether the vendor goes broke, whether they terminate their contract with them, the person who signed the contract dies, or whatever it is.

You should always be able to get the patient data out. And anyone has problems doing that, they should call the Office of Civil Rights.

…And if the EHR vendor says, "You have to pay extra," and they're holding you hostage, then you complain to the regulators that this EHR vendor is not fulfilling what they should be fulfilling as part of the certification rule, which is to let you have a batch download of all your data.  So be empowered in that. Be empowered in your contract.

ME: Can you comment on the fact that EHRs are one of the main drivers of physician burnout? How can we move past physicians being data collectors to restoring their role as caregivers?

FM: I think there are a lot of factors that are driving burnout. I don't know that the data is clear. I think that one of the major causes of burnout isn't the EHR per se. It is this loss of control and feeling that you're not in control and that there's a whole host of things, whether it's prior authorizations, whether it's a big insurer telling you what they're going to pay you and it's less than Medicare pays, whether it's the rising cost of everything and the decreasing reimbursement for everything and new rules that come out that you can't even understand.

I had one good friend who closed down the doors of her practice. And it wasn't because of the EHR. And it wasn't because of Meaningful Use or ACOs. It was the accumulated frustrations of trying to be a small business owner and trying to stay independent with all of this stuff coming on [physicians].

The key is two things. One, if you're in a kayak in the rapids, you have to lean in and dig your paddle in and push ahead. If you lean back, you're done. You're going to flip over. So be more active. Don't be passive. Take control. Step two is join together with others to increase your power, increase your control, increase your ability to have someone else help you deal with that crap, deal with the quality reporting, deal with the EHR optimization, deal with the ACO regulations.

So I think that's the solution-not to retreat into some direct primary care model. That, to me, is not a solution for all of our docs to say, “I'm not going to take insurance.“ That's not the solution. We have to find ways of coping with the change and feeling more in control.

ME: Will America ever achieve EHR interoperability, or will we be torn apart by competing corporate interests who use HIPAA as their defense more to increase their profits than to protect anyone's privacy?

FM: I'm, thankfully, seeing a little bit less of the HIPPA excuse. And there's been a lot more kind of proactive guidance on the part of the Office of Civil Rights that basically says that's BS. And you can't hide behind that particular fig leaf. But interoperability is now a business problem. It is not a technology problem.

We have to change the equation to make it more profitable for vendors to share information than to horde it and, frankly, for hospitals to share information rather than horde it. So on the vendor side, if people purchased systems on the basis of how well they spoke with other systems, then they would change. They listen to their customers. And so it goes back to making sure you have the right contractual terms, and make sure … you're clear in your selection in terms of what your priorities are.

On the hospital and provider side, it is worrisome to me. Our docs went to the big local hospital-and I'm not going to name them here-and said, "Give us those admission-discharge-transfer notifications" [largely seen as the go-to data source for care coordination efforts]. And the hospital said, "If you're part of my ACO, you can get that. But if you're not part of my ACO, we view this information as strategically important."
The fact that it's your patient, you're the primary care doctor for that patient, that you are the one that needs to call that patient and that it's their patient's life here at stake, that can't stand. And I do think that there needs to be more regulatory oversight over these sort of misuses. I do think the Federal Trade Commission should look into these as being anti-competitive because it clearly is misuse, abuse of market power. I think that people need to speak out when they see this sort of informati