As Farzad Mostashari, MD, prepares to leave the ONC, his office and  the Centers for Medicare & Medicaid Services are looking to the future and plotting long-term information exchange and interoperability policy strategies. Between meaningful use Stage 2, which is heavy on health information exchange, and the Affordable Care Act’s delivery and payment reforms in Medicare and Medicaid, the “overarching policy intent” is enabling care coordination and collaboration.

“We cannot have it be profitable to hoard patient information,” Mostashari said during a CMS and ONC webinar, emphasizing an idea he has long nurtured.

Offering a long-range vision and noting healthcare’s complexity — compared to, say, standardizing ATMs — Mostashari explained that federal health IT policies and programs are foundational tools, but not single solutions in their own right to the problems facing American healthcare.

Meaningful use incentive payments and EHR certifications “are not enough to achieve the widespread interoperability and HIE necessary for delivery and payment reform,” Mostashari said.

[See also: Interoperability in its 'last mile'?]

And the context in which EMRs or HIEs are being used by providers is paramoount, he added. “How tools are used is critical to how care is paid for and the incentives for healthcare providers.”

Indeed, the incentives created by fee-for-service reimbursement in Medicare and private insurance have been well-known contributors to the problematic volume-based provider business model, and Mostashari himself cheers the advent of quality-based payment models and the decline (if slow coming) of fee-for-service, occasionally using the Twitter hashtag #FFSdemise. 

Now that the industry is moving in that direction, Mostashari said it’s still important to have stakeholder input, from providers, payers and patients — and they are weighing in. CMS and ONC received a lot of responses to a recent request for information on advancing interoperability and HIE.

Among those suggestions: requiring digital HIE in all advanced payment models and Medicaid waivers; including long-term care, post-acute care and behavioral health providers in CMS’s state innovation model grants; extending Meaningful Use incentives to long-term, post-acute and behavioral health providers; creating reimbursement codes for care coordination enabled by tele-health and digital consults, radiology queries and evaluation and management; and extending legal exemptions for hospital EMR donations to physicians under the Stark Law and Anti-Kickback Statute.

While several of those and other ideas are being explored, Mostashari wanted to mention three projects the ONC is working on in the short-term.

[See also: Practices embracing HIE, replacing EHR.]

“We have a road map towards information being able to be exchanged and used” — standards, interoperability and certification, he said. But the ONC and CMS haven’t really explained that all succinctly enough for hospitals and physicians.

“There are still far too many questions from stakeholders. We need to provide that transparency” and “communicate better,” he said. “We can’t assume they’re going to go the S&I Wiki, and listen to the S&I calls to get a sense of the road map.”

On the long-term care and behavioral health fronts, the Health IT Policy Committee is in the process of determining the scope and criteria for voluntary (“and I emphasize voluntary,” Mostashari said) EMR certification program.

And the ONC is working on open source tool kits for admission discharge transfer applications that could notify a patient’s primary care doctor or hospital if they end up in an emergency room after a recent hospitalization.

CMS, too, has some priorities for expanding HIE by way of Medicaid and long-term policies, said Julie Boughn, the deputy director of the Centers for Medicaid and CHIP Services.

As one webinar attendee asked Boughn, would CMS approve Medicaid state plan amendments that use administrative funds to incentivize health information exchange by Medicaid managed care organizations?

Boughn did not answer whether or not administrative funds would be transferable for state Medicaid programs, but said there are several ways for states to use authority under the HITECH Act and Medicaid to incorporate HIE requirements in Medicaid reimbursement models, as the Oregon Health Authority is doing under a recently-approved federal Medicaid waiver.

And Medicaid waivers and state plan amendments are also ways states may be able to bring long-term, post-acute and behavioral healthcare providers into the HIE care continuum — because Medicaid is the largest payer of long-term care and support services.

Another HIE landscape that Mostashari will be watching, likely beyond his time at the ONC, is patient-mediated exchange, as in patients facilitating the digital sharing of their medical data.

Mostashari said that the so-called “HIE of one” model is “possibly the most disruptive, in a good way, that may really accelerate far beyond what we could accomplish.”

Before digital health data can follow the patient, and even as it does follow the patient, Mostashari added, the “first step is making sure patients can get access to their data.”

Stage photo from Shutterstock.com.