Farzad Mostashari: Let me be blunt

No longer constrained by the talking points that are part and parcel of life in public office, Farzad Mostashari, M.D., took the stage at the annual CHIME CIO forum in Scottsdale, Ariz., on Wednesday and spoke frankly about barriers to care transformation, limits of healthcare technology and other worries he has about the healthcare system.

And for the first time since stepping down as the national coordinator for health IT, he gave an unofficial answer to the question everyone always asks in some form or another and about one program or another: Will Meaningful Use Stage 2 be delayed?

"I'm no longer in public office and I can be blunt," Mostashari (pictured right with CHIME President and CEO Russell Branzell) said. And blunt he was.

Barriers to care transformation

"We've been shackled," he said. "Trying to change a system like healthcare? It's really hard. And when there are forces that mitigate against that change in so many different ways, that are keeping the status quo in place, it becomes nearly impossible."

Preventative medicine, he noted, supports the common value of making people better, but runs counter to every other force. "So we may have a fantastic ability to reduce unnecessary asthma hospitalizations and if the hospital loses money doing the right thing, it can't survive."

There are others in the healthcare industry that can work on these problems in their own way, Mostashari said. The exciting thing about working on it with health IT as a tool? "What we have is something that gets better. Technology gets better," he said.

"Every one of you is going to have an opportunity to lead around care transformation. Every one of you can choose greatness for the transformation of your organization and to be strategic partners in that transformation. Not service line but transformation agents."

Worries about health IT

The health IT community is dedicated to making healthcare better, Mostashari said, but it is also constrained by systems that are sometimes lacking. "That's what you're addressing. You're addressing the lack of systems, the lack of information, the lack of rational engineering processes and protocols, the application of data and learning to our healthcare processes," he told the audience.

"We have now a lot of new payment systems that are going to need totally new thinking, totally new use of information, totally new processes and systems. And I have to say, I'm very hopeful, I'm very optimistic in general. But in terms of the progress we've made in having new policies [and] technology ... I'm a little concerned ... and I'll share with you now--no longer as national coordinator--some of my worries and concerns."

Among them:

People and organizations are unprepared for the new forms of care delivery: "We can talk about population health management all day long. We can even buy population health management software," he said. "But flipping the practice, flipping the hospital, changing so that everything doesn't have to take place in an eight minute doctor's visit that is what we can get reimbursed [for] under fee for service? Creating standing orders and protocols? That's a cultural challenge. That's not an IT challenge. That's a business practice challenge. And one thing you all have going for you is that you've learned that being a CIO is as much about change management and governance as it is about electronics. You're going to have to use those tools to the max. You're going to have to be really strategic ... in terms of using the technology not as a bludgeon ... that's not going to get the motivation we need."

Product usability isn't keeping up with expectations: "I didn't think there was a clear government role as much as there was a market role, and I don't know if the market is incentivizing usability as much as maybe it could," he said.

Time limits and pressure of looming projects such as ICD-10 and Meaningful Use: "The other worry, of course, is time," he said. On one recent hospital visit he asked how much time staff spend on problems other hospitals have already solved, such as creating order sets or developing an early warning system. The answer: A lot. "That development time is unnecessary. Everyone rediscovering that same thing is not necessary," he said. "Helping others is the only way we get through this."

That kind of help has to be more systematic, though, he added. "Vendor user groups are good. Vendor-provided platforms where you can share modules or content? That's good. It just doesn't feel like we're having enough of that happening to get us through this next difficult period."

Supply of products that solve problems isn't keeping up with demand: "Innovation is kind of what keeps it fun, right? ... We want to invent our way out of our problems," he said. But there's a gap in terms of matching up supply and demand of new products--there are a plenty of ideas but not enough businesses based on them. Developers of products such as readmission predictors need partners, clinical understanding and a place to try out their innovations, he said. And from the CIO's perspective, it's hard to evaluate and choose one product out of the thousand readmissions predictors floating around out there.

And the question everybody always asks ...

In the second half of the event, Mostashari took questions from the audience in a Q&A session with CHIME President and CEO Russell Branzell. Will Stage 2 of Meaningful use be delayed? 

"I think folks should assume that the timelines stick," he said.

But there is the potential for flexibility within the current policy, Mostashari added.

"I'm sensitive to all of the pressures that are here and would argue for flexibility in terms of the timing. Let me give you some insider clues, though, in terms of how this request would play on the policy side."

Anything that's in the regulation is subject to a nine to 12 month rulemaking process--back to proposals, public comment periods, and so on, he said. "Just think about the impact that would have ... A notice of proposed rulemaking as to whether we should delay the end date for Stage 2? It would be total chaos. Because no one would know what the final rule's going to be. We can do sub-regulatory guidance. That's where I would advise CHIME to look. Don't make requests or suggestions or recommendations that will be difficult to meet. Think about what can be done."

Branzell asked for an example of sub-regulatory guidance that might offer providers some flexibility.

"It's in the rule that people can ask for hardship exemptions," Mostashari said. "CMS can clarify what constitutes a hardship exemption. You wouldn't get the incentive payment, but you wouldn't get the penalty 1 percent Medicare cut, either."

But policy makers, he said, are focused on the larger impact of any decision, such as a delay. There are problems (some of which he addressed in an exclusive interview with FierceHealthIT).

"The first is interoperability. We can't wait for interoperability. It's past time. And we have a whole series of really important standards. We got consensus from everybody, we put them in the final rule, everyone's had plenty of warning and we need everyone to step up to those standards," he said. 

To Learn More:
Mostashari to leave ONC
Mostashari resignation surprises hospital CIOs
Farzad Mostashari to join Brookings upon ONC exit
Jacob Reider named Acting National Coordinator for ONC; temporary replacement for Mostashari
Mostashari: Health IT has evolved into an inevitability
John Halamka: 'Shrinking budgets' will define next National Coordinator's reign



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