Outgoing tech czar Mostashari offers thoughts on incentive payments, interoperability, IT centers

By Joseph Conn

Posted: October 4, 2013 – 12:01 am ET
Dr. Farzad Mostashari served more than two years as the nation’s fourth federal health information technology czar during the busiest time in the history of healthcare IT. He stepped down Oct. 5 as head of the Office of the National Coordinator for Health Information Technology at HHS after having led the rollout of a nationwide network of health IT extension centers and an incentive program for the adoption of electronic health records that has paid $16 billion to reward 82% of eligible hospitals and 60% of eligible physicians and other professionals for demonstrating meaningful use of the technology. Modern Healthcare reporter Joseph Conn spoke with Mostashari as he approached his departure from the administration, just as many in the industry and some lawmakers were leaning on his office to ease up on the timeline for providers and vendors 
Modern Healthcare: What is the appropriate role of government in catalyzing something like health IT
?Dr. Farzad Mostashari: One of the lessons here for us—and maybe it’s timely—is to think about that question as: What is the role of government and what are the challenges we have that the market is not sufficient for addressing?And prior to the HITECH Act, there was a lot written about why wasn’t the adoption of electronic health records bringing healthcare into the age of data? Why wasn’t that just happening on its own?And the diagnosis was that there were market failures, that people who needed to be invested in IT weren’t the ones who were seeing the advantages. There were challenges with getting the standards implemented because of the way that market players compete on the basis of their proprietary standards, which didn’t serve the patients. There was a lack of information or technical assistance for the smallest practices.What the legislation really created was the possibility of addressing each of those market failures through very targeted, finite, but necessary government action. For Medicare as a purchaser, we get more value out of our dollars if it’s delivered through electronic health records, and we’re going to pay a little bit more if you do it with health records, and after a while, we’re going to pay a little bit less. There are standards that we’re going to work with the community to come up with and endorse, and there’s going to be a certification program that’s going to encourage the adoption of those standards nationwide and to provide not a heavy hand—and not the invisible hand leaving it all up to the market—but a helping hand through the regional extension centers.MH: Could you have achieved these levels of adoption absent this incentive payment program?Mostashari: No, I don’t think anyone could seriously look at the progress and say, “Oh, yeah, that would have happened anyway.”

Also, we could look at other countries as kind of our controls, right? In Canada, I don’t think there’s been a single hospital that went up to Stage 7 (of the industry EHR adoption standards), whereas, we’ve had a huge increase in shifting hospitals from Stage 4 and 5 to 6 and 7.

MH: Before you got to ONC, you were involved with what was, in effect, a regional extension program for health IT in New York City. What is the role of the regional extension centers going forward?Mostashari: I’m really proud of the regional extension centers. Atul Gawande wrote a couple of pieces about the agricultural extension program and how we needed an analog for healthcare. I feel like, don’t you know about the regional extension centers? They’re that good. They’re that important and may be the largest medical technical assistance project in history to reach 40% of all primary-care providers in America.From Alabama to Alaska, every primary-care provider has an opportunity to work with an extension center. The fact that rural health IT adoption is not less than urban health IT adoption is a testament to the hard work of extension centers working with the providers and others to make that happen. I certainly hope that folks see that value.I do have a concern, though. Once people associate something with the price of free, it’s very hard to make that shift, and we have tried to have some cost-sharing in place to make sure that the people pay something. Some practices that may be willing to pay $50,000 for a consultant may not be willing to pay $5,000 for their extension center because they expect someone else to foot the bill on that. I sure hope that they can make it through the transition.MH: There has been a lot of pushback on Stage 2 meaningful-use criteria. Some senators are calling for a partial delay. It’s already been delayed a year. We have ICD-10 coming up. What do you think about the pacing right now?Mostashari: We earned the moniker of the Office of No Christmas because we felt a sense of urgency and we lived it ourselves, and I think everyone has felt like there’s been a series of consecutive sprints over the past four years, so I understand the sense that many have, in particular those on the front lines. And I think for Stage 3, we certainly heard the comments that we shouldn’t be really doing rulemaking on Stage 3 until we give people a chance to be able to get up to Stage 2.But on the other hand, how long do we have to wait for interoperability? Do you want a delay in interoperability? I can tell you that Stage 2 is a critical, critical piece of the entire industry, the entire field of healthcare in America.

There is a whole ecosystem out there waiting to flourish around personal health records and consumer technology and that data. Do we want to delay the ability of patients to get access to their own information in an electronic format? We have to make some tough judgments as a country here, and we have to recognize that any of these extensions or delays comes at a very real cost to interoperability, lives and to the ecosystem itself.

So my advice would be, there should be no hesitation about realizing that we need to, as a country, be using 2014-certified software by the end of 2014—we just need to do that.

Now, tweak it up to Stage 2, saying let’s wait and see what the experience is with Stage 2, and let’s see what happens in Stage 3 and what the construct is for Stage 3. I think that’s a debate that we can have. But we have rules, we have regulations, we have the certifications, we have the software, and we need to have the will to go ahead and step up.

Now, I will point out that many of those who are most worried don’t have to worry about meaningful use in Stage 2 until 2015 or later because it’s only those who attested by 2012 that would need to step up to Stage 2 by 2014. So there is a built-in escalator, and I think there’s still far too many folks who are saying, “I’m a rural hospital. I haven’t even tested in Stage 1 yet. I can’t go to Stage 2 in 2014.” And we’re like, “No, you don’t have to.” I think the associations can do a better job of getting the facts out there to their members.

MH: Any word yet on your replacement?Mostashari: There’s a national search, and I am confident that it will be the right person for the right time. (Dr. Jacob Reider has been named acting national coordinator.)MH: What are you going to be doing next?Mostashari: I don’t know. I should maybe ask my Twitter followers for recommendations. <<Note: On Oct. 3, Mostashari announced via Twitter that he would be “joining the Engelberg Center for Health Care Reform at the Brookings Institution.

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