Mostashari's Health IT Vision
In this Q&A, Health IT Outcomes gets the newly appointed National Coordinator of Health IT's take on EHR effectiveness, troubling EHR research, and ensuring patient privacy in an electronic world.
Within days of his appointment as the new National Coordinator of Health IT for the Department of Health and Human Services, Health IT Outcomes had the opportunity to interview Dr. Farzad Mostashari. We asked our subscribers, as well as members of HIMSS (Health Information Management Systems Society), to submit their questions for Dr. Mostashari to ensure our question set reflected the voice of the healthcare IT industry. The following is a transcript of the resulting conversation.
HTO: In your role as national coordinator of Health IT, do you plan on making any changes to the meaningful use roadmap currently being developed by the ONC? If so, what are they? If not, how do you plan on carrying the torch from this point forward?
Dr. Mostashari: I don't plan on making any changes. I think that we have a terrific and robust framework in meaningful use. It's the right framework and the right strategy. The main message I plan on promoting is one of continuity. I've been a part of this office since July 2009 serving as the Deputy for Programs and Policies, and I believe that the policies, programs, and partnerships that we've put in place are the right ones. And, our partners and healthcare providers are moving ahead in the implementation of the program we've put in place.
That being said, we have to continue not only follow through with meaningful use, but more importantly, stay true to the principles that got us to where we are today. These principles include keeping our eye on the prize, but our feet on the ground; using the market, but making sure it is open to all; putting the patient at the center of everything we do; and having open, inclusive, and participatory processes for our policymaking. These are the principles that we used to develop meaningful use and these are the principles that we will continue to value as we look to the future.
HTO: Much of the ONC's efforts to date have focused on EHR adoption and meaningful use. What other Health IT initiatives do you feel are imperative in the near-term?
Dr. Mostashari: Someone once said "data is oxygen," and there is a lot more oxygen in the air today than ever before. Some of the most interesting innovations are going to come on top of, or building off of, the data that is now going to be electronically collected and used by providers in their healthcare improvement and transformation efforts. Whether it's reducing readmissions and improving care coordination, sending patients reminders in innovative new ways such as social networking or text messages, predictive modeling, or better forms of decision support — all of this becomes possible when you build on the foundation of the data being more liquid and more electronic.
The other area that I see emerging is in the consumer e-health space. When consumers have access to their own data in a format that they can use and reuse, the possibilities are astounding in terms of the "disruptive" (and I use that in the Clayton Christensen sense of the word) innovation that can emerge. The rapidity of innovation in the consumer marketplace far outstrips what is feasible in the clinical enterprise. I see a lot of exciting potential in that sector, and now is the time for us to focus even more on the patient-centric uses of Health IT.
HTO: A significant amount of research exists that indicates EHRs have no impact, or even a negative impact, on productivity, operational costs, and patient care. How do you respond to this research and why do you personally believe that having the industry achieve Stage 3 meaningful use is a good thing for the U.S. healthcare system?
Dr. Mostashari: I think some of the research that has been one to date is biased, in a sense. Sometimes a small study, or even flawed study, has a kind of "man bites dog" aspect to it, and there's often a lot of ado about one particular finding this flawed study dredges up. I think people tend to over-generalize from those types of sporadic studies. So, I think what's needed is a comprehensive, exhaustive, systematic, and scientific analysis of what the literature over the past three years regarding EHRs has actually shown. Dr. Melinda Buntin and her team recently did exactly that, and their findings were published in Health Affairs last month.
Dr. Buntin and team had very strict eligibility criteria regarding the material they would review for the study, and approximately 150 articles on EHRs met their protocols. What they found was that 92% of these studies actually illustrated that EHRs were a positive endeavor for healthcare facilities. So, I think overall whether you look at access to paid care, preventive care, care processes, patient satisfaction, patient safety, provider satisfaction, effectiveness of care, or efficiency of care (and they looked at each of those), the overwhelming evidence is more positive for EHRs, and there were relatively few negative studies. So, I do have absolute confidence that the appropriate and meaningful use of Health IT is not only a good thing, but an essential thing for our healthcare system. We simply need better information.
Proof of this is evident by taking a close look at what simply isn't possible in a paper world. For example, you can't go into a room full of paper charts and say "Will all the patients with diabetes that haven't had their A1C levels checked please jump out at me?" You can't send reminders to all the patients over the age of 50 that haven't gotten their flu shots yet with a room full of paper charts. You can't ask as paper chart to slap you in the face and remind you to order the lipid test for a certain patient that might be at risk for a heart attack. You simple can't do these things in a paper world. For this reason, I have complete confidence that EHR adoption and meaningful use is an essential part of healing our healthcare system.
HTO: If EHRs are the answer, how does the ONC intend to use HIT to improve patient safety and avoid creating a huge body of electronic patient data that can potentially be exposed?
Dr. Mostashari: We absolutely have to ensure the privacy and security of health information and the public's trust. To that end, there are many ways in which EHRs are actually more secure than paper records. For example, you have no way of knowing who has looked at your paper chart. With an EHR, this information is easily captured and tracked. In fact, audit logs are one of the requirements for EHR meaningful use. In addition, you can't segment a paper chart and provide clerical staff with access and viewing privileges to one portion of the chart and not the other. You can absolutely do this with an EHR by leveraging user-based access features. Another example is encryption. You can't encrypt parts of a paper chart (except through bad handwriting), whereas with EHRs this is certainly feasible. And, don't get me started on faxes that are misdirected. For years, I would get woken up at 2 AM or 3 AM with faxes from hospitals, despite my repeated attempt to get them to stop passing me confidential patient information to the wrong fax number. That kind of thing happens all the time. So, I think we have to recognize that our current paper- and fax-based systems aren't so hot either. At the same time, we need to do everything we can to ensure the privacy and security of health information. I think one part of that is going to be to develop ways of learning about what is happening, measuring the quality of care, understanding public health trends, or answering research questions while having the data stay where it is instead of being all centralized in one big data center. I think that is some of the more interesting work that is happening now from a research perspective now and it will be an increasing part of what we call the learning healthcare system.
HTO: With ARRA/HITECH EHR incentives, HIPAA 5010 compliance, ICD-10 compliance, and healthcare reform, healthcare IT professionals have a lot on their plates. Is the federal government asking too much of healthcare providers from a technology adoption and change management perspective? What advice would you provide healthcare facilities struggling to juggle all of these initiatives? How would you advise them to prioritize?
Dr. Mostashari: I've helped more than 200 small doctor's offices implement EHRs in some of the country's poorest neighborhoods. I know how hard it is and how many different things are on a healthcare provider's to-do list. So, I think what we have to do is shrink the change. We need to make it easier for people to take the first step. We have to provide help, and we've made that help available. That first step may be call your Regional Extension Center.
The other advice would be to take it a step at a time and to recognize that effective implementation of an EHR isn't a distraction from what they are going to have to do to succeed in Accountable Care, for example. Instead, EHRs should be viewed as a roadmap for how you can succeed in a world where your livelihood is going to be dependent on providing higher quality care, safer care, more coordinated care, and more patient-centered care. I think we need to re-double our efforts to ensure the adoption and meaningful use of EHRs truly serve as a jumpstart for practices to do what they know they will have to do in order to thrive, or perhaps even survive, in the coming years.