As National Coordinator for Health Information Technology, Farzad Mostahari, MD, has, since 2011, led the government's efforts to transform the nation's healthcare structure into a 21st century digital system. The goals are to improve patient care, increase efficiencies and lower costs. Mostashari delivered a rousing keynote talk at HIMSS12, and he is slated as a headliner again this year (Thursday, March 7, at 8:30 a.m.).
Healthcare IT News recently asked Mostashari for his thoughts on some of the major work ahead on the health IT front.
Q: In a recent blog, you wrote about many achievements that have already occurred on the way to transforming healthcare. Is there something you wish had happened that hasn'thappened so far?
A: I've got to be realistic in terms of the context of how variable capabilities are throughout this great country of ours, and how variable the vendors are in their capabilities. One thing I talked about at the first Health IT Policy Committee meeting of the year was the need for vendors to step up on some issues. We can't deal with everything through government regulation. There's got to be some self regulation, some social regulation, some codes of conduct that go between government regulation and individual, competitive greed or competition - you know, just doing what you can to get what you can. I get a lot of complaints from docs, providers, hospitals about some vendors - I don't want to tar the entire industry, but some vendors, some products - about the usability of the systems. They complain about people slamming things into certification that don't really work in the real world, or aren't consonant with workflows; about opacity in terms of pricing, being nickeled and dimed, or being surprised by fees that seem to not match what would be reasonable expectations. There's concern about contracts that appear to limit the ability to report safety issues; or about lack of real progress on creating an enforceable commitment on the part of vendors to themselves to report any safety event. Those are some of the issues. And then there's interoperability. Most vendors really do see it now as part of their self-interest to be as interoperable as possible, but we still hear a lot of complaints from providers that their vendors are putting up what they believe are artificial roadblocks to them being able to share information, to participate in health information exchange.
Q: Talk about that lack ofinteroperability: What has to happen to change it? Does it have to come from the vendors?
A: It's a shared responsibility. Fundamentally, we have to reduce the cost and complexity of interfaces through standards and implementation guides. The vendors have to really be able to do Stage 2. It's a huge step up on interoperability. Vendors are really going to have to step up to the plate in terms of being able to achieve the Stage 2 expectations for true vendor-to-vendor coded, clinical structured, documents being able to have kind of ubiquitous protocols with security in place. That's a big step for the industry and meaningful use Stage 2 sets the tempo and expectations for that.
Q: Apparently you believe that will happen.
A: I think it's not going to happen by itself. It's going to need a lot of work on the part of the vendors, but also for us to help provide examples, tools forums, education. This is the year where implementation happens for Stage 2 - getting ready. Governance is also a piece of that. We decided against a regulatory approach to governance. But that means, again, these public-private groups need to step up and create the common rules of the road that people will voluntarily adhere to, and common approaches. So that is also a work in progress and something we have to push hard on to get to that kind of trust. And the customers have to be demanding of interoperability of their existing vendors and particularly when they're thinking about purchasing new systems or replacing their system. If the system does not interoperate, if the vendor doesn't seem committed to interoperability, you should look elsewhere. Because the future of healthcare is going to be the need to coordinate.
Q: What about the usability of EHRs? How will better design come about?
A: We have the SHARP program. We work with NIST. We have usability guidelines. We have certification requirements around user-center design, transparency around user-centered design approaches, quality-measuring processes. We've got a lot of stuff going on in the usability area in addition to the SHARPC program. There are some areas that you expect that fierce competition may not yield public benefit of the greatest good. Maybe proprietary standards might be a good example for that. But I don't see why fierce competition should not be occurring around usability. And, indeed if we look at products today, they're a lot more usable than they were four years ago, and I hope they're going to be a lot more usable four years from now - even things on the hardware side. The explosion of tablet use in medicine, I think, is having a tremendously positive effect on usability of the systems. So I think there it is less of a government role, probably - we can do some things around transparency, clear guidance and so forth - more around the marketplace, where customers need to make it one their top priorities, and vendors need to increasingly focus on delivering not just more bells and whistles, but simplicating and adding lightness for a change.
Q: Some say interoperability is a decade away. What do you think?
A: Interoperability, as Doug Fridsma (director of ONC's Office of Science and Technology) says, is not a destination, it's a journey, in the sense that it's constantly evolving. There's always going to be new needs, new requirements for interoperability. We're going to constantly have to keep stepping up towards greater and greater levels of being able to share information and understand the information once it's shared. I believe that we have made more progress in the past two years on interoperability, motivated by the meaningful use incentive program and by collaboration and the open inclusive process to get to consensus, than the decade before. I think Stage 2 is going to be a big step up. We also have a lot of irons in the fire around query-based transactions, around query health, and many other S&I (Standards & Interoperability Framework) initiatives that are going to bear fruit - no, not 10 years; in the nearer term.
Q: What is the most important game changer on privacy?
A: The game changer is going to be healthcare waking up to the importance of meeting the expectation that our patients have of us: That we're going to do everything we can to keep their information private and secure. The game changer is the changes in attitudes towards the importance of security and privacy. But in terms of the HIPAA modification specifically? To me, the part of it that was the most interesting and important was the business associates - clarifying how the obligations of covered entities are translated forward and are binding on business associates. It's not just the records that are kept in the doctor's office or in the health plan. There's a whole range of service providers and business associates that help with the processing of information. And we're seeing that more and more of the breaches that occur can be tied back to shoddy practices on the part of business associates. So, I thought that was a very important safeguard.
Q: The Rand Corporation recently issued a report that kind of walked back what they had stated in a previous report about anticipated savings for the healthcare system from use of IT. How do you see it?
A: My interpretation of that was they revisited their report. They didn't so much as walk it back as to say, I thought, two important things. One was that it's going to take time. You can't assume that the second you publish a paper you can start to book the savings. You have to have high levels of adoption. Adoption's gone up a lot, but it's still not 80-90 percent. You have to have interoperability, and they say there's progress made, but we're still not there yet. You have to be able to share information with patients in a structured way, which is in meaningful use Stage 2, so progress has been made, but we're not there yet. So, make sure there are reasonable expectations in terms of timing of when you can expect to see this bending of a cost curve. I thought that was their first important contribution in that paper. The second was to make more clear than they had in the previous paper that this is not a magic pill. That it's not like you can drop health IT in without thinking about the context, and say, well, what's the effect on cost saving? It's a tool. And the context, particularly of what we pay for, matters a great deal in terms of whether we use this tool to deliver care - that you get more health and more, better care at lower cost. The good news is that those changes are happening, and being able to marry together the changes in how care is paid for and how care is delivered really can offer dramatic - not just life-saving, but also be the answer to how we get out of the fiscal and budget difficulties that our healthcare system and our country are in.
