Justin Graham, MD MS
Congress left a $19 billion treasure trove for physicians and hospitals in the HITECH provisions of the recent ARRA stimulus package. This particular pot of gold, however, lies at the other end of a magical rainbow labeled “meaningful use of certified electronic health record (EHR) technology.” Like all rainbows, the definition of “meaningful use” is a glittery, insubstantial thing that shifts as one’s perspective changes and encompasses a wide spectrum of colorful views; but, even to experts, it remains unclear if the rainbow can become a bridge across the quality chasm that defines American healthcare.
While we wait for a final determination from Washington, the healthcare community has been witness to a panoply of colorful attempts to define and re-define “meaningful use.” HIMSS, the Markle Foundation, CHIME, AMIA, and other titans of healthcare information technology have added their voices to the spectrum of viewpoints. Largely absent from this debate have been those most likely to be profoundly affected by the HITECH incentives: front-line, practicing physicians, and their patients.
“Meaningful” is in the eye of the beholder; unfortunately our fragmented healthcare delivery “system” has more eyes than a potato. “Meaningful use” to a patient might imply a reduction in risk of a life-threatening drug interaction or less paperwork or shorter waits at the doctor’s office. In contrast, “meaningful use” to a physician in a small practice might mean better reimbursement, more leverage against strong-arm insurer tactics, or just getting out of the office before 7pm every night. Certainly, insurers and payers might like to see EHRs improve the quality of care, but they clearly have a vested interest in seeing that improved quality results in greatly reduced costs. And, of course, a whole host of vendors, foundations, and public and private HIT organizations have their own agendas, including explicit or tacit support for standards or technology they are fully invested in.
I’ve spent more than 10 years working with healthcare information technology, including spearheading EHR efforts in settings as large as Kaiser and as small as the solo practice, rural physician office. After all this experience, I don’t think I can conclusively create a global definition for “meaningful use” for an EHR any better than I could do it for an automobile or a screwdriver. In the right hands, an EHR is an incredibly powerful tool to create dramatic changes in healthcare delivery and quality. But, in the end, it is only a tool, a means to an end, which has no more value to an unready healthcare provider than a car does to New Yorker who has taken the subway his entire life.
The last thing we want from this grand, national experiment in subsidized information technology is “meaningless use,” which might be a bit easier for us to define. After all, a vandalized and stripped car by the side of the road is fairly easy to deem “useless.” How would we universally define “meaningless use” of an EHR? Here are some suggestions:
· EHR implementations that lead to unambiguously worse outcomes for patients without hope of improvement. For instance, increased deaths in ICUs when computerized order entry malfunctions.
· A series of highly visible failed implementations that scare providers (and even patients) from adoption of HIT over the next decade.
· Cynical use of HIT solely to support higher salaries for providers or reduced costs to insurance companies without concomitant improvements in quality of care
· Widespread adoption of technological “dead-ends” that lock providers into proprietary data models and interfaces, eliminating the possibility of future innovation and improvement of the healthcare delivery model
Like most others in my field, I passionately believe that information technology can dramatic transform healthcare for the better and improve the lives of our patients, providers, and staff while reducing costs. But what will ultimately differentiate “meaningful” from “meaningless” use will not be the technology itself, but rather competent leadership, change management, efficient processes, and a relentless focus on the patient before everything else. Those who believe they can reach the pot of gold by walking on a rainbow are fooling themselves; the surest way to get there is step by muddy step across the solid ground.
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