Farzad Mostashari, M.D., deputy national coordinator, programs and policy, in the federal Office of the National Coordinator for Health Information Technology (ONC), spoke recently with HCI Editor-in-Chief Mark Hagland regarding his perspectives on the progress being made by providers on meaningful use, under the HITECH (Health Information Technology for Economic and Clinical Health) Act. Dr. Mostashari will be the opening keynote speaker at the HCI Executive Summit, to be held May 11-13, 2011, in San Francisco, Calif. ( www.HCIExecutiveSummit.com). Below are excerpts from that interview.



Healthcare Informatics: What can you talk about right now, with regard to progress on meaningful use?

Farzad Mostashari, M.D.: I can talk about the principles we're using to help drive our strategy. First of all, let's talk about the importance of having these principles, not only for our senior leadership, but for our staff. In some ways, our staff is relatively new. And we want our staff to feel empowered to make decisions; but we don't want them to get off the farm, off the reservation, so to speak. So we can give them a sense of guidelines, a design framework.

LET'S BUILD ON WHAT'S ON THE GROUND TODAY, AND ADAPT. BUT THE TECHNOLOGY EVOLVES VERY RAPIDLY; AND WE NEED TO BE CONSTANTLY AGILE, MONITORING AND ADAPTING, AND AWARE OF WHAT'S GOING ON IN THE REAL WORLD.

And principle number one is, “eye on the prize.” You can never be reminded enough that the goal is not IT itself. The best articulation of this is our policies and programs in the meaningful use framework. We didn't start with the technology; we started with the goals of quality, patient safety, care coordination, and so on. So at the end of the day, you move forward, based on backwards-towards-the-goal planning. Otherwise, you end up with IT for the sake of IT. So principle number one is, “eye on the prize.”

Principle number two is, “feet on the ground.” Let's build on what's on the ground today, and adapt. But the technology evolves very rapidly; and we need to be constantly agile, monitoring and adapting, and aware of what's going on in the real world. An IT corollary of this is, “don't rip and replace.” And another corollary is “bold incrementalism,” building on what you've got.

A good example of this is health information exchange. In some ways, we were building for version 5.0 before version 1.0 was in place. So we said, let's start with something that will add value now, and that departs as minimally as possible from what's in place policy-wise now, yet adds value. So it will end up in some ways being incredibly bold, but it starts with the question of what is the simplest set of protocols that can ensure the security of data as it moves from one place to another. And basically, SMTP protocols have been embraced, but because we started with the lowest common denominator, we've been able to get the participation of the major EMR vendors, lab system vendors, and so on.

HCI: Do you think clarity is emerging now on what works in HIEs?

Mostashari: I think we need to establish a universal base of simple exchange that can support planned care and simpleness, so that when a patient asks for their record, or asks for their record to be continually forwarded to their electronic health home, that can take place; and so that when someone sends a referral, that that can take place. I think that's transformative, and I think we will create a universal base for the facilitation of care coordination. Now, not all care is going to go as planned. And we want to minimize how often we rely on these safety nets, right? But inevitably, someone will end up in an emergency room, and the information won't have followed them. So in most cases, you need to develop local networks of trust-and you get there by sharing, and by showing leadership locally. And there aren't that many technological models, there are more governance models there. I think in the upcoming 12 months, we're going to remove a lot of the uncertainties. And I'm seeing a rapid warming of interest in that area.

YOU NEED TO DEVELOP LOCAL NETWORKS OF TRUST-AND YOU GET THERE BY SHARING, AND BY SHOWING LEADERSHIP LOCALLY.

And a third principle is, “foster innovation,” and its corollary is, “use the market.” There are ways that government can play a role in fostering innovation, and we're doing that through some of our grantees. But more important is creating the policy context around which innovation can flower-things like permitting modular certification. But importantly, it's to fundamentally have a market-based approach where people can compete. And when you look at what we're doing compared to what many other countries have done-using the market and fostering the market, is a key part of our approach, and that is different from other countries. An example of that is the regional extension center program.

And the fourth principle is, when you use the market, the role of the government is to watch out for the little guy.

HCI: Some people are concerned that the net effect of the certification program and the short timeframes will be to solidify the positions of the largest EMR vendors, and foster consolidation. Your thoughts?

Mostashari: I don't think we're seeing that. Number one, demand is up; and two, the established vendors have their hands full, and people are going to be looking for alternatives. Number three, we now have some sophisticated purchasers who are willing to take some risks. And in terms of the regional extension centers, it's really interesting: many of them are looking to local vendors, local companies, and saying, we can partner with you, and help you improve your product to meet the needs of our customers. And you can have not only the benefit of marketing that you might not otherwise have had, but also the benefit of our providers in terms of getting feedback on what they want. And in turn, you'll become more responsive vendors. And the other element here is modular certification, where you don't need to do everything in the marketplace.

HCI: One area of deep and immediate concern among some healthcare CIOs has to do with the need, under the current rules, for hospital organizations to essentially obtain multiple certifications, if they want to use best-of-breed emergency department or other solutions, since right now, the way the rules are written and articulated, there is no allowance for the use of a core EMR minus an ED system, for example.

Mostashari: It's a bit of a complicated discussion there. And by the way, we have over 180 products now that have been certified, within weeks of certification opening. So I see that theoretical concern, but the evidence doesn't bear it out. Meanwhile, the bottom line is that people have to have certified products, and you have to buy what a vendor certifies. So it's really a vendor decision as to whether they certify their product in total or in chunks; and it's really their customers that have to make the decision as to whether to tell the vendor, I don't want to use your ED module, so you need your product certified without the ED module. But I don't see it as fundamentally a real problem.

HCI: Do you have any closing thoughts?

Mostashari: I just want to underscore once again the principles we're following: eye on the prize, feet on the ground, foster the market, and watch out for the little guy. And that's a critical role for the regional extension centers, to act in the best interest of the providers, and resolve asymmetries. And finally, everything we should do should be in the context of an open, transparent, and democratic process. We've really tried to adhere to the principles of open government. So those are the five principles; and the “plus one” that goes with them is, always put the patient at the center. So whenever there's a debate, we ask, OK, what's best for the patient here? And that's incredibly clarifying. We've made incredible progress in the last year. I think we have the right strategy, the right people, and the right partnerships; I think we have the wind at our backs in many ways. I think a lot of providers will adopt and achieve meaningful use; I think it will create momentum and critical mass; I think we'll make important progress on information exchange this year. It's going to be hard for everybody, but it's gratifying work, and we think we'll end up with a transformed healthcare system that delivers higher quality, greater patient safety, and increased efficiency.

Healthcare Informatics 2011 March;28(3):51-52