Howard Landa, MD
What is “Meaningful” for Physician’s office?
Over a decade and a half of HIMSS (Healthcare Information Management Systems Society) meetings, many are identified in my mind with “catch phrases” and mnemonics. We had “Patient safety;” “to err is human;” and “interoperability." There were RHIOs and CHINs; CPOE and CDS to prevent ADEs as part of EMRs, and EHRs; and these were hotly debated by CIOs, CMIOs, and CEOs, all looking for ROI.
At the end of 2008, I thought that HIMSS 2009 would be a much quieter meeting than in the past. The downturn in the economy had cut everyone's travel budget as well as their ability to make capital investments. But then along came the mnemonic and catchphrase of 2009; ARRA (the American Recovery and Reinvestment Act or Stimulus package), and the phrase “meaningful use.” And HIMSS 2009 came alive! The ARRA promises to provide a great deal of money to physician offices and healthcare organizations that can show “meaningful use” of electronic health record. There is no question in my mind that implementing efficient, effective, well thought out EHRs in ambulatory care has the potential to dramatically improve the quality and efficiency of medical care. As has oft times been said, however, “The devil is in the details!”
The definition of meaningful use in the case of electronic health records is being hotly debated. The best and simplest definition I could find for “Meaningful” was “The quality of having great value or significance,” and this is an apt definition to begin with. To obtain “meaningful use” from electronic health record should mean to bring real value from having a clinician interact with an electronic system as care is provided to a patient or a population. As we look at the details that could compose “meaningful use,” we always need to return to this guiding principle.
One of the first questions that comes to mind about “meaningful use” is the definition circumscribed, static situation, or does it change with times and progress? Is meaningful use in 2011 the same as it will be in 2016? Can we start off with the bar placed low to encourage early adoption and gradually make the demand more stringent? Or is the safety and benefit being extracted from “electronifying” medical care one that has to provide the requisite advantages at go-live?
One of the first items in the “meaningful use” shopping cart is often discussed is the idea of CCHIT certification.
This certification ensures that a certified electronic health record has the ability to manage clinical records and automate the physician’s workflow; ensure patient privacy in safeguarding personal health information; and ensures the ability to send and receive electronic health data between entities like laboratories and pharmacies.
Additional requirements for 2008 include electronic prescribing with clinical decision support (weight-based dosing, allergy and drug-drug interaction checking), and management of documentation such as consents. Other issues include the obvious need to be able to do quality tracking and reporting (needed even now for Pay for Performance (P4P) and of course questions about how much of a clinician’s daily work had to actually be done using the system.
No one will argue that these are all excellent functionalities for EHR to provide, and some, like insuring patient privacy are vital, and already “the law.” Are they all required, though, to ensure meaningful use? Are these of great value?
Large physician offices may be able to leverage these workflow optimizations and pay for it with economies of scale, but what of smaller practices? Do they need to have a system this elaborate to provide meaningful use?
Let’s look as some specifics, starting with CCHIT certification.
I don’t think there will be much discussion about this for hospital or large organization that are installing EHRs. They will both need and want their vendor to be certified, but is it necessary for a small physician practice? The process is not inexpensive and the enhancements many office based system vendors will need to make may be substantial. There are hundreds of these smaller vendors and many have not sought the certification for just this reason. If the certificate is necessary to obtain the stimulus dollars, no practice will endeavor to put in a non-certified system. I think it likely in that case, that many of these vendors may go out of business rather then attempt certification. One of the stated missions of the ARRA overall is to increase employment helping businesses survive and prosper. What happens if the HIT portion of the plan puts a large number of small businesses out of business? And what about practices that have already implemented a system that is not certified. I do not foresee a “grandfathering” and even if they did, vendor support will rapidly dissolve if new sales are not forthcoming. How is this of ANY value?
Electronic prescribing is touted as the single functionality that separates electronic health records from document management systems. It should provide increased patient safety due to legibility and can enhance efficiency by electronic transmission, as well as enabling many types of clinical decision support. These may be as simple as suggested medications by clinician or problem, extending through drug-drug and drug allergy checking, and goings as far as weight-based dosing and treatment recommendations. It even provides the ability to manage large populations relative to medication concerns or drug recalls. But is it the legibility, decision support, or the electronic transmission that is required to obtain meaningful use? Where is the value proposition? The implementation and upkeep of a “complete” system will be substantial and how will the benefit outweigh the cost.
Reporting is an issue that worries many clinicians. They see it as a slippery slope starting with something as innocuous as P4P reporting. If system are truly back end standardized (harping back to interoperability certification) will requirements to produce more and more data be put on practices? Will physicians be judged and rated based on their data? Will there come a time when the system you put in (with government support? Ah there is the rub!) be spying on you?
-After all, if there is a requirement to minimal use the system (e.g. “>75% of your medication must be ordered electronically” or “>50% of clinical documentation much be available electronically”), there is going to have to be some way of reporting on this, right?
-What will come next, documentation as to how often you verified allergies…
-Or how often you do medication reconciliation…
-Or how good are you at providing health maintenance services…
-Will a patient’s urologist be “dinged” for not providing flu vaccinations?
-Will a family practitioner be chastised for not referring a patient to urology if they are diagnosed with hematuria?
And what if a practice implements a system that does not meet the “meaningful use” criteria; or say refuses the ARRA funding. Will they be exempt from having to “participate” in these data collection activities? Is the incentive money really blood money? And what about when the incentive money runs out? Will the systems be implemented to comply with the meaningful use as defined by the government; to the detriment of true efficiency and ROI optimization? The true cost of implementation will certainly exceed the incentives in the long run; unless there truly is a positive return on the physician’s investment.
So perhaps I am channeling Chicken Little and everything I am worrying about truly is paranoid speculation? Let us say it all works as we hope it does. Are we then creating a government sanctioned Ponzy scheme? After all these vendors ramp up and practices install systems over the next few years, then what? We are not likely to see such huge innovations that practices will want change vendors or do major (i.e. expensive) reimplementation’s in the short term. Will vendors with only maintenance revenues be able to survive and continue their R&D effort at a sufficient level? Or is the sky really falling?
I look forward to the thoughts, ideas and speculation of those much smarter then I!