Print BCTV: Obamacare Glitches - How healthcare IT efforts affected by Obamacare online meltdown

Obamacare Glitches

Transcript of BioCentury This Week TV Episode 162




Dr. Farzad Mostashari, Visiting Fellow, the Brookings Institute




Health and Human Services




High Tech Act of 2009

Stimulus Act



Microsoft Health Vault

No More Clipboard



Steve Usdin, Senior Editor




STEVE USDIN: Obamacare's online meltdown. Is this what we can expect from healthcare IT? We'll ask Farzad Mostashari, former Obama Administration Health Information Technology Czar. We'll ask him what's gone right, what's gone wrong with health IT, and his prescription for the path forward. I'm Steve Usdin. Welcome to BioCentury This Week.


NARRATOR: Your trusted source for biotechnology information and analysis, BioCentury This Week.


STEVE USDIN: Glitches in federal healthcare exchange websites have focused the world's attention on the role of information technology in healthcare.


BARACK OBAMA: And starting on October 1, private plans will actually compete for your business. And you'll be able to comparison shop online. There'll be a marketplace online, just like you buy a flat screen TV or plane tickets or anything else you're doing online. And you'll be able to buy an insurance package that fits your budget and is right for you.


The problem has been that the website that's supposed to make it easy to apply for and purchase the insurance is not working the way it should for everybody. There's no sugar coating it. And I think it's fair to say that nobody is more frustrated by that than I am.


STEVE USDIN: As important as the Affordable Care exchange websites are, they're only a small part of the massive federal government investment in healthcare IT. And they're only the tip of the iceberg when it comes to trying to use technology to improve medicine. The Obama administration started down the path of using information technology to reform healthcare long before the enactment of the Affordable Care Act.


The stimulus investment and the health IT requirements in the Affordable Care Act are banking on technology to create the kinds of efficiencies in healthcare that have transformed retail and service industries. And the hope is that technologies like mobile apps can empower patients. One individual has personified the government's efforts to drive health IT -- Farzad Mostashari who recently resigned as National Coordinator for Health Information Technology in the Department of Health and Human Services. Today, we'll hear his vision for using data to transform medicine and empower patients and his candid assessment of what's gone wrong and what's gone right in health IT.


To discuss the past and future of health information technology, I'm pleased to be joined by Dr. Farzad Mostashari. Dr. Mostashari, I know you weren't involved in doing it, but I have to ask you, because people have the expectation -- how did the federal online exchanges get so screwed up?


FARZAD MOSTASHARI: Well, as you started off by acknowledging, that wasn't my area of involvement.


STEVE USDIN: As an informed outsider, you've got about as good a position as anybody.


FARZAD MOSTASHARI: I guess I could speculate, just like everyone else is speculating about the insurance exchanges. I guess the insight that is not a very novel insight is that IT is hard. And if you look at a single hospital's information system, getting that set up and running can be a journey of several years. And this was a pretty big undertaking. But fundamentally, I think the idea that I want to make sure people understand is the Affordable Care Act is not a website.


And the provisions for people to get insurance and to be able to do that are certainly going to be greatly aided by the ability to do online shopping. But that's not the only thing that is available and the only way in which insurance eligibility is expanded, including through Medicaid. But also, people I think are not understanding how the Affordable Care Act wasn't just about insurance, for the 15% of the population who doesn't have insurance. And it's really important to help them get affordable health insurance.


That's really important. But everybody else is not getting very good healthcare either.


STEVE USDIN: I want to go back to that. But one other question about the exchanges. Then we'll move on the other things that you really want to talk about. If you look at it, when you were a coordinator for healthcare IT, your job wasn't to write code or to even buy code, it was to set standards and then to set the marketplace, where you want loose on it. If you look at it, maybe there's an analogy in the online exchanges.


The federal government set the standard for the states. And the states have been far more successful than the federal government has. Is that a lesson from this?


FARZAD MOSTASHARI: And the Federal government didn't want to be in the business of running those exchanges. And in fact, the law really imagined and provided funding for the states to set up those on the marketplace. And it was only really by default that the federal government had to take on the work of those state exchanges. But you're right that in my role as National Coordinator for Health Information Technology, it was about helping doctors and hospitals adopt healthcare IT to use computers to take care of their patients, not just their billing.


STEVE USDIN: The way I look at it, there's two things. Health IT in itself is not an end. There's two things that are really interesting that it can do, as far as I'm concerned. The first is patient empowerment, which I want to talk about later in the show.


And the second one really is facilitating improvement of the way medicine as a whole works, the way that payment reform can work, the way that providers can integrate with each other and so on -- population health. Can you talk a bit about that in the context of the Affordable Care Act?


FARZAD MOSTASHARI: The Affordable Care Act also made some really significant changes in how healthcare is paid for. To move us away from -- you know, they say you get what you pay for -- so traditionally, we've been paying for things to be done to people: heads in beds. We've been paying for visits, we've been paying for procedures, we've been paying for stuff to be done.


STEVE USDIN: And stuff gets done.


FARZAD MOSTASHARI: And guess what? What we end up with is a lot of procedures, a lot of hospitalizations, but we're not incentivizing outcomes. So if I talk to a primary care provider, and I say, spend that extra time on helping the person quit smoking, they're like, I'm going to go broke. That's what's best for the patient, is going to keep them out of the hospital.


STEVE USDIN: How can health IT help that?


FARZAD MOSTASHARI: So the first point is that the Affordable Care Act said we're going to change how healthcare is paid for. My mom got admitted to a hospital a few years ago for a routine knee operation. And she had complication after complication. And unfortunately, that is so common. One out of every three Medicare patients has some sort of complication during a hospitalization.


If she gets readmitted back to the hospital, if when she gets discharged, they don't have very good follow-up instructions or very good coordination or a good pass off to the primary care doctor, if she got readmitted back to the hospital within 30 days, that hospital made more money. Think about that. If that hospital invests in reducing the complications, they made less money.


That's fundamentally broken. It's indecent.


STEVE USDIN: And that's one of the things that is supposed to change under the Affordable Care Act.


FARZAD MOSTASHARI: And the Affordable Care Act changed that.


STEVE USDIN: Well, it is changing. I wouldn't say it's changed it overnight. I don't think you would. We'll talk about that when we come back. First, I want to talk about that the Veterans Administration has pioneered the use of medical data to empower patients. Here's a look at the Blue Button Initiative, which started at the VA and has been widely adopted.


BARACK OBAMA: Veterans will be able to go to the VA website, click a simple blue button, and download or print your personal health records so you have them when you need them and can share them with your doctors outside of the VA. That's happening this fall.


NARRATOR: You're watching BioCentury This Week.




STEVE USDIN: We're talking with Dr. Farzad Mostashari about using data to transform medicine and empower patients. Dr. Mostashari, we just looked there and we saw President Obama talking about the Blue Button Initiative. What is it? And what is that an example of what can be done, what patients can actually do with data?


FARZAD MOSTASHARI: What it fundamentally says is, you have a right to your data. And knowledge is power. And if we open up and if we let patients have their own information, whether it's the VA doing it, whether it's 37 million Medicare beneficiaries, like my mom and dad being able to download three years of every claim Medicare has paid on their behalf, or whether it's now increasingly, if you go to your doctor's office or the hospital, you're going to be able to go online and download your medical records to have and also to access a whole variety of apps and services that are going to be built up to help you manage your health and healthcare finances.


STEVE USDIN: So that seems to be a key thing, because the big thing in advancing health, as opposed to advancing the business of health is going to be changing behaviors. It's going to be smoking cessation, weight loss, things like that.


FARZAD MOSTASHARI: Medication-taking.


STEVE USDIN: Adherence. So how can apps and data help with those practical things that are really important?


FARZAD MOSTASHARI: That's the exciting thing, is instead of us pre-judging that and saying, we want someone to build a service that will do x, y, or z. You let the market, you let all those Silicon Valley start-ups -- and this is the hottest area of venture capital investment right now is this -- is taking data and helping people find services that'll help them manage their health, their healthcare, and their healthcare finances, because increasingly, there's going to be not just the responsibility on patients but the ability for them to be able to have transparency in terms of price and quality, in terms of what providers they choose.


STEVE USDIN: So that's people empowering people. One of the things that I've seen if you talk with people anecdotally about is the way that some health IT is integrated into the medical system is that it's a computer that's literally between the doctor and the patient.


FARZAD MOSTASHARI: We try to tell docs not to do that.


STEVE USDIN: That's what I want to get into. Is that something that's inherent in integrating computers into medicine? Or is it something that's wrong with the technology, or something wrong with the way doctors are using it?


FARZAD MOSTASHARI: It takes time to learn how to use the different technology. So what we teach providers to do is to have it be a triangle. So this is the screen, literally. And you can both look at the screen. You can say, here's what I'm saying. You're saying that you had it for three weeks of.


And you can chart it, and you could graph it. And that becomes a tool for patient education, instead of a laptop that's hidden from the patient. So it's really all about, how do we take this technology and how do we change how we deliver care to make it better?


STEVE USDIN: So one of the things that people also have an imagination about, when they think about the government making standards that are going to require a lot more electronic health records, they imagine there's some giant electronic health record out there, and that your insurance company is going to get it, maybe your employer's going to get it, things like that. Is that what's happening?


FARZAD MOSTASHARI: There is no vast government database of all your medical records. What we did was we said doctors and hospitals need to be able to have their patients' information electronically. They need to be able to share it with each other. This is where the second stage of meaningful use -- technical term -- will come in. And really importantly, there is a place where all your medical information can be aggregated: you.


You will have the ability to say, give me all of my -- you can go to your health plan, you can go to your doctor, you can go to your hospital, you can say, give me my data. And I will put it in one place if I want to. And I can share it with whoever I want to share it with.


STEVE USDIN: And will it be in a standard so that from all of these different places, it can all be combined?


FARZAD MOSTASHARI: Exactly. So what we did was we set the standards. And this was an indispensable role for government, to say, we're going to convene people across the industry -- competitors. And we're going to say, let's choose one set of standards for how the vocabulary that's used, how it's packaged, how it's transported securely and privately so that the systems can understand each other. And that's going to take effect over the next 12 months.


STEVE USDIN: We talked about this general idea of population health and electronic health records and health IT facilitating populations. Can you be a little bit more specific about what is it and what we can it really do it in real life.


FARZAD MOSTASHARI: So imagine that you have a room full of paper charts. And you want to make a list of all of your patients who are on the medication that was just recalled by the FDA. You can't do it, unless you have a magic wand and you say, all those charts fly out of the air. Send them an owl.


You can't do that. With electronic health records, you can make a list of those. If you want to make a list of patients who did not come in to see you, that's the power of being able to use electronic health records to do population management, not just to have a transactional, like selling soap, selling shoes, patient walks in the door and you say, how can I help you, pull their chart.


You can do that with paper. What you can't do with paper is to say, of all my patients with diabetes, how many are on that statin?


STEVE USDIN: So that presumes that somebody's taking a step back. And it's not going to be the physician who's overburdened, who's spending all their time going from patient to patient to patient, hoping that they can catch up on some of the medical literature and grab a little to sleep and then come back and do it again. Does that mean that somebody else has to be taking a step back and saying, how can we use this data to make health better?


FARZAD MOSTASHARI: I do think that it's associated with the physician's role being different from what you just described, which is the hamster wheel of going from patient to patient to patient to patient and never being able to ask the question, how am I doing as a whole? How's my practice doing?


How can I be a team leader instead of the only person who's doing all this? Why does the doctor have to be the one to type in the information on that? That's not meaningful use. That's just the office practice.


Why can't the patient put in information? Why can't the clerk put in information? Why can't the nurse do some things? Why can't we have automatic protocols that say, if the person needs a mammogram ordered, by golly, it's ordered?


I don't have to order it. The nurse can do that. The order is there automatically. You can take it off.


STEVE USDIN: Isn't part of that also, that it's also going to enable patients to be able to know which doctors are doing best, which facilities have the highest quality or something like that? Are we going to be able to get that out of it? How is that going to happen?


FARZAD MOSTASHARI: So that is part of the Affordable Care Act, is more transparency around quality. And I think we're moving towards more transparency around cost as well so that patients who increasingly have high deductible plans, they have to make choices about which provider and provider networks to be part of, they can choose based on quality, objective measures of quality, as well as safety, as well as patient experiences and cost.


STEVE USDIN: That's interesting, because you talk about objective quality, because otherwise, you get something like it's a Yelp or something like that where it's just anecdotes, and it's going to just be the negative anecdotes are going to be up there.


FARZAD MOSTASHARI: I want to know before I sign up for a surgeon to do knee replacement on my dad, I want to know:  what's the complication rate for that provider? What's the redo rate for that provider?


STEVE USDIN: Compared to somebody else.


FARZAD MOSTASHARI: Compared to other providers. So that's information that increasingly we're going to be able to have.


STEVE USDIN: More in a moment with Dr. Farzad Mostashari.


NARRATOR: Health are is changing, and we are changing too. Each week, watch BioCentury's Affordable Care Update, a special part of every show dedicated to keeping you informed about this unprecedented transition. And watch all of the weekly updates in one place at any time only at




NARRATOR: Now, back to BioCentury This Week.


STEVE USDIN: Dr. Farzad Mostashari is the former HHS National Coordinator for Health Information Technology. Dr. Mostashari, I think a lot of people watching the show are going to say, that's wonderful, the stuff you're talking about. But I'm not seeing that in my life. Amazon and iTunes do a lot better job of integrating my technology than my doctors do.


Can you give us an idea of how far we've come in last couple of years, where we are and where we're going to get to what you're talking about?


FARZAD MOSTASHARI: So the big thing that changed everything was the High Tech Act of 2009, the year before the Affordable Care Act.


STEVE USDIN: Part of the Stimulus Act.


FARZAD MOSTASHARI: Part of the Stimulus Act that said that doctors and hospitals could get incentive payments if they not only bought health records, but they used them in certain ways, like sharing information with patients or with each other or sending electronic prescriptions. And at that time, four out of five doctors didn't use electronic health records. Nine out of 10 hospitals didn't use health records to order prescriptions, to take care of patients.


STEVE USDIN: That's in 2009.


FARZAD MOSTASHARI: That's in 2009.


STEVE USDIN: And today?


FARZAD MOSTASHARI: And today, it doubled and tripled and quadrupled and quintupled among hospitals. And now, we see 2/3 of doctors offices and 3/4 of hospitals are on this path towards meaningful use of electronic health records. But that's only the first stage. And you will have undoubtedly seen this in your own doctors' experiences, where they're going through a transition, and now they're trying to figure out how to use these computers.


STEVE USDIN: And cursing at them.


FARZAD MOSTASHARI: And cursing at them. But that's just the first step. That's just digitizing it. But the next step in the process is where it gets really exciting, which is the sharing. And that's stage two of meaningful use.


STEVE USDIN: Interoperability . . .


FARZAD MOSTASHARI: The interoperability, which is the standards now been promulgated, the 2014 certification requirements for these electronic health records. And if we can continue on the same accelerated path we've been on, in 2014, we will see huge differences from every time in the past.


STEVE USDIN: And what's going to mean in a very practical way for patients, for the medical system?


FARZAD MOSTASHARI: That means that if you get discharged from a hospital, your primary care doctor will be able to get the information from your discharge. When you show up at a specialist, they will have your records, instead of turning to you and saying, why are you here?


STEVE USDIN: So you're not going to be going in and filling out on that clipboard anymore?


FARZAD MOSTASHARI: I sure hope not. You'll be able to get your own medical information. And there will be interoperability between those two systems. So the drug you get here and the drug the vocabulary they use in the other place will be synced up with each other. That's stage two of meaningful use, the interoperability piece of this.


But really, once the data starts to flow, what gets really exciting is the ability to learn from it, for systems to learn from it, to learn what's working and what's not working, to move towards better outcomes. We're just now taking the baby steps in terms of the data revolution that has transformed every other industry finally coming out.


STEVE USDIN: If I go on Amazon, it does a pretty good job of predicting what books I might be interested in reading next. If I go to my doctor, there's an electronic system there now that predicts what might happen to me, how I might respond to medicines, things like that.




STEVE USDIN: So when we do get to that? And how does that happen?


FARZAD MOSTASHARI: Well, maybe that's stage three.


STEVE USDIN: So some of the other things that the people talk about is using electronic data to track diseases, for example. And there's an example that to people like to talk about Google, that they could track flu symptoms and predict where the flu was. That isn't such a simple story, is it?


FARZAD MOSTASHARI: Well, I think the main point is that with a lot of data, you can make a lot of inferences. But the problem is, you generate from the data some insights. But you've got to get to action. You've got to be able to test it. There's a lot of signals that happen.


There's a lot of potential outbreaks out there. But you still need the boots on the ground. You need those public health workers. You need those doctors and emergency room physicians to be able to run it down and be able to get to what's actually happening on the ground.


And I think that's why we can't just have big data in the sky. We need to have small data in the clinic and in the health department.


STEVE USDIN: And what are the kinds of things that need to happen then to make big data actually something that's going to change people's lives and change medicine?


FARZAD MOSTASHARI: I think we have to unleash the creativity of American entrepreneurship on this. As we do this, the one key thing that we really have to constantly be aware of is privacy. There should be no surprises for people.


STEVE USDIN: And let's talk about privacy issues and how your protect privacy when we come back. We'll talk to Farzad Mostashari about that and get some other final thoughts.


NARRATOR: Now in its 21st year, visit for the most in-depth biotech news and analysis. And visit for exclusive free content.






STEVE USDIN: We're back with Doctor Farzad Mostashari, talking about privacy and data. Dr. Mostashari, you ended there, and you were talking about privacy. What do we have to do to ensure privacy on a personal level and at a societal level?


FARZAD MOSTASHARI: Everyone has to do their part. And patients really are putting their trust in their healthcare providers, their doctors, hospitals, to keep their information private and secure. And those providers need to take that of the utmost seriousness. I hear every day laptops that are stolen where the information wasn't encrypted.


That should never happen. If you're going to put patients' information on a thumb drive or a laptop, first of all, think really careful about why you're doing it. Second of all, for goodness sake, just encrypt it. Server rooms should be locked.


There's basic protections that are part of HIPAA, part of the security rule, and part of meaningful use that providers just need to take very seriously. It's also the vendors that they work with, the business associates often times now, you pass off the patient data to someone else to analyze it for you, to clean it for you, or whatever. Those entities now, with the HIPAA modifications that took effect, those also have those same responsibilities.


But it's also patients. If you use a service to store your personal health information -- increasingly, there'll be more and more services like this, from Microsoft Health Vault to, to No More Clipboard -- there's a whole host of services like this now. Make sure you understand their privacy policies. And there should be a simple, one-page, kind of like a bank statement, that explains what they do with your data.


If you don't see that simple explanation of what they do with your data, who they share it with and so forth, don't use that service. And make sure that you take the steps you need to make sure the information, if you store it, is encrypted or it isn't persistent on your devices.


STEVE USDIN: So if people have their health data on their computer, on their smartphone --


FARZAD MOSTASHARI: You should use apps that encrypt that information, or make sure that you at least have good password protections on things.


STEVE USDIN: Earlier you said that there's one place where all the data is going to be, and that's going to be with the patient. That puts a lot of, on the one hand, responsibility on the patient, on the other hand, ability to do things with it. Most patients think that medicine is something that happens in that eight minutes that you're with a doctor. But actually, health is something that happens all the time.


What can people do with their data in practical ways? And what are they going to be able to do in the future?


FARZAD MOSTASHARI: I think it's really going to change. I think that you're exactly right. There's responsibility, and with that, empowerment. And those are the two sides of that coin. I think we hear about ways in which the healthcare system doesn't serve patients well. There are safety problems.


So for the one thing, ask to see your record. If you're there and the doctor's typing behind you, you don't know what they're typing, you have every right to see what's in that record. What are the medications they have you on? Check it.


Maybe it's not right. Oftentimes, it's not right. And that could be a potentially fatal issue for you. So taking that responsibility or doing it for your family members, your loved ones. People with diabetes, their risk of dying in the next three years is cut by 50%, if they're on a statin. And only half of people who should be on that are on a statin.


I want that conversation flipped. Instead of the doctor wagging the finger at the patient, saying, you should do this, and you need this, and you should get a whatever, I want that to be turned the other way, where the patient says to the doctor, hey, based on the best scientific evidence, I need, I deserve, I should have. That, I think, is going to be profoundly different in our healthcare system but profoundly positive.


STEVE USDIN: And that's something that can be enabled by these kind of apps that we're talking about, where patients know exactly what it is or the standard of care that they should be able to be getting. Thanks, that's a fascinating conversation. I'd like to thank my guest, Dr. Farzad Mostashari.


Remember to share thoughts about today's show on Twitter. Join the conversation by using the hashtag #biocenturytv. I'm Steve Usdin. Thanks for watching.