Mostashari Reflects on Tenure at ONC

by Kate Ackerman, iHealthBeat Editor in Chief

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After four years at the Office of the National Coordinator for IT and two years serving as the country's health IT czar, Farzad Mostashari announced last month that he would step down from his post this fall.

As the country's fourth national coordinator for health IT, Mostashari became well known for his trademark bow tie and contagious enthusiasm for all things health IT.

Among other things, his legacy includes helping to spearhead the meaningful use incentive program, promoting the use of data to improve health care and stepping up federal efforts to boost patient engagement.

As his last day at ONC quickly approaches, iHealthBeat caught up with Mostashari to ask him to reflect on his work at ONC, discuss what qualities his successor should have and comment on his future plans.

iHealthBeat: You've been at the Office of the National Coordinator for Health IT for four years and have served as the national coordinator since 2011. Your predecessors -- David Blumenthal, Robert Kolodner and David Brailer -- served for similar lengths of time. How did you come to the decision to step down this fall?

Mostashari: You know, for someone who prides himself on evidence and data, it was a highly unscientific process of listening to my heart. And, it just felt like a good time. These are intense jobs, and it's been an intense four years for me in public service that I wouldn't exchange for anything. But I knew that I wouldn't be effective if I stayed another three years to the end of [President Obama's] term.

And, given that, once it was clear to me that I wasn't going to be here the full rest of the term, I thought leaving while things are relatively stable -- the organization was in pretty good shape, we're between rulemaking cycles -- [and] getting the next national coordinator here at a time when they can really put their stamp on the next stage would be the wise thing to do.

But honestly, it just felt right. And, it's felt right ever since I told [HHS Secretary Kathleen Sebelius]. I haven't had any regrets.

iHealthBeat: Looking back at your tenure at ONC, what accomplishments are you most proud of?

Mostashari: I really have to stress that I didn't accomplish anything by myself. And, these are accomplishments not just of ONC, of the 170 really dedicated public servants, but the accomplishments of a larger community that have put really blood, sweat and tears into making a better health care system over the past four years.

Viewed in that light, the accomplishments that I think we as a community can be proud of is just how far we've come. Just a few statistics. At the end of 2008, we had, what, like 6% of prescriptions that were sent electronically? And, now over half. We had 9% of hospitals that had a basic electronic health records. It's now quintupled. The data [are] lagging on this, it's probably a great majority of hospitals. We have 90% of hospitals in the meaningful use program. We have 80% of doctors, from Alaska to Alabama, in the meaningful use program.

Really increased used of these capabilities -- of being able to do safe prescribing, look at your own quality of care, do evidence-based care, make a list of patients, population health management function, sharing information with patients, the Blue Button movement. I mean there's so much that's happened in a really short amount of time for health care. The axiom is that it takes 17 years for any innovation to make it into widespread medical practice. Well, we've taken a huge bite out of this defining challenge of moving health care into the age of data.         

iHealthBeat: And what about the flip side? Do you have any disappointments? Is there anything you wish would have played out differently or any area in which you expected the country to be further along than it is?

Mostashari: The disappointment -- if there is any -- is how far we have yet to go on optimizing the use of the technology. Changing, redesigning and re-engineering care processes to take full advantage of the technology. So that's the big challenge that we have for the next four years probably, and maybe even longer, is going to be that continual process of optimization, of using the tools and more and more and more skillfully. That I think is a big challenge.

iHealthBeat: I interviewed you back in April 2011, just a few weeks after you were named the new national coordinator.

Mostashari: Ah, what did I say back then?

iHealthBeat: In fact, I'll tell you. I asked you about your top three priorities for the office. The first priority you cited was implementation. You said, "I know that from personal experience in implementing electronic health records in small doctors' offices and community health centers and hospital outpatient departments it's hard work, but we do have help in the regional extension centers and our workforce program, and it's time to implement." The second priority was "making sure that what we do is clearly understood as linking to health outcomes and delivery system transformation. ... It's not IT for the sake of technology. It's about improving health." And, your third priority was "doubling down on the concept of the patient in the center of everything we do."

So, two-plus years later, how would you evaluate the country's progress in these priority areas?

Mostashari: I think we've done a really good job on two of them, which is the first and the third. Implementation -- the initial implementation, adoption, getting to meaningful use Stage 1. As I said, with everyone's blood sweat and tears, and the really remarkable display of grit and creativity from the providers and vendors and the regional extension centers. That, I think, succeeded my expectations that I would have had two years ago.

On moving toward the new paradigm where it's not just about doctors and hospitals, but really tapping into the democratization of health information for patients, I think we're just in a vastly different place than we were two years ago. Where we were when we had our first consumer e-health summit in September of that year and where we're going to be on Monday when we have our third consumer e-health summit, [it is] vastly different. Things like the view, download, transmit capabilities that every doctor and hospital that wants to be part of the meaningful use program has [through] certified technology, that's a game-changer and a half. And, that's made huge progress.

Despite I think our beliefs and how we think about meaningful use and health IT, how we construct the policies to be absolutely working backwards from the outcomes -- like helping people live longer and not killing people and talking to each other and not wasting money -- those are our goals, and that's why we come up with the policies we do come up with, I still wish we could have communicated better on the why of why we're doing all of this.

Because still too often I hear from people who don't understand why. And, it seems like a series of regulatory compliance mandates instead of understanding how they connect not only together but also with what we're seeing on payment reform, paying for value, paying for outcomes and on care transformation activities. They're absolutely in line with those. They can be used meaningfully. Meaningful use can absolutely be used meaningfully to help providers get to a better health care system and to meet the challenges of new payment models. But I still think we need to do an even better job of communicating the why and how they all come together.

iHealthBeat: I know you can't comment on specifics about your successor, but what sort of attributes do you think the next national coordinator for health IT should have?

Mostashari: You know we've had four very different national coordinators in temperaments and backgrounds, and I think we've all done all right for using our strengths and also, for me at least, knowing where I needed a team to help me round out my strengths and surrounding ourselves with a team that can complement what we bring. So I suspect that'll be true for the next national coordinator as well.

But some of the fundamentals of this role I would say one is listening. In this job, it's really important. It's moving very rapidly, and there [are] a lot of different stakeholders. And no matter what experience you had on the outside, once you get inside, it's really important to keep listening and hearing and being in touch with what's happening in doctor's offices and hospitals in communities. So that's a skill that is absolutely necessary.

And the other corollary of that is to always be learning and open to and curious and to expand what knowledge one has. Because this is such an interconnected field. There [are] the really deep technical issues. There [are] the really legal and regulatory understanding. There [are] the privacy and security issues. There's the health reform understanding, business cases. It's understanding some about market dynamics. It's understanding data and evidence. Understanding medicine and population and public health. So no one is going to have all of those. So the ability to learn on the job is I think No. 2 requirement for doing this job well.

And being able to communicate is always important. As I said, we can always communicate better. And this is such an important role for the national coordinator -- not only to be the director of a small federal agency with 170 dedicated staff members, but also the voice of a community of people that believe that health care can be better through the use of information and are fundamentally optimistic about the future. I think that's important.

iHealthBeat: And, what kind of advice would you give to the country's next health IT chief?

Mostashari: Well there's some of it that will remain private (laughs). But I think it goes back to these points. It's to always be listening and to always keep the goals firmly in mind. But I suspect that whoever is next will bring something new and wonderful to this role that I didn't have. So really be yourself. That's good advice to anybody in any job -- self-awareness and being yourself.

One of the things that has helped me and will undoubtedly help them is that the national coordinator I think will sometimes unfairly get the credit for a lot of things that staff do or the community does as a whole. So trust that you will be carried by them just as I was.

But take the long view. That's the other thing. It's so easy in these jobs to get wrapped around the axel of whatever the newest micro issue is that's the issue of the day that our helpful journalist friends are writing about. But to really take the long view. This is not a sprint, this is a marathon.

iHealthBeat: You are very active on Twitter. You've posted more than 3,500 tweets and have more than 11,000 followers. And, as I'm sure you know there is even an @FarzadsBowTie twitter account that was created in your honor. What's your take on the role of social media in health care and specifically in health policy?

Mostashari: Well, I love it because it helps me do those two things. One to communicate, but also to listen. Because one of the great things about Twitter is that anyone can call you a chump. And, you know again, don't get wrapped around the axel of every little blog that gets amplified, but it's a way of hearing directly not from the bloggers necessarily but from the real-world practitioners in terms of what they're experiencing and how they're reacting.

iHealthBeat: Last question for you. Can you give us any clues about your post-ONC plans? How involved do you plan to stay in the health IT community after you step down?

Mostashari: My plan honestly is to finish my job, finish this out. Oct. 5 is going to be my last day. So finish this job strong and then spend some time making a plan. So my plan is to make a plan.

In a funny way, I never thought of myself as a health IT person. I've always thought of myself as a health care and public health person -- someone who brings those communities closer to each other through the use of data and information. And in that broader sense, I know that I will always be a part of this broader defining battle of our times.


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