Meaningful Use vs. Meaningless Adoption of Electronic Health Records

Dr. David Blumenthal, the new National Coordinator for Health Information Technology, has stressed that  the goal of the ARRA/HITECH initiative is to improve patient care, not to mindlessly adopt health information technology. In this regard, he wrote that many CCHIT-certified EHRs “are neither user-friendly no designed to meet HITECH’s ambitious goal of improving quality and efficiency in the health care system.”

It is therefore disconcerting that the Association of Medical Directors of Information Technology (AMDIS) just weighed in on the issue of meaningful use with their letter to Dr. Blumenthal, recommending that the new national HIT Policy Committee use the 2008 CCHIT certification criteria to determine which hospitals and physicians get HITECH incentive dollars.

Even more disturbing is the AMDIS recommendation that meaningful adoption (their newly coined term) substitute for meaningful use until at least 2013.

We see placing the reporting of quality measures in advance of reporting measures of meaningful EHR adoption as akin to putting “the cart before the horse” — the fields that form the basis for automated quality reporting must first be populated on a regular basis . . .

What’s going on here? As I read it, AMDIS is acknowledging that CCHIT-certified EHR technology is so difficult for hospitals and physicians to use that it will take years of training before meaningful use can even be addressed. AMDIS states that process of EHR adoption and use must follow a ‘crawl-walk-jog-run’ progression requiring continuous cycles of training and practice that ‘cannot be skipped or shortened’ [italics mine] without risking failure, introducing errors, and causing the frustrated physicians to give up.

Most disquieting of all is the AMDIS recommendation to exempt hospitals (but note, not office-based physicians) from HITECH’s computerized physician order entry (CPOE) requirement until 2013 or beyond. AMDIS states that even in the hands of its most experienced members, working with EHRs that are already up and running (most inpatient EHRs are CCHIT-certified according to HIMSS) successful implementation of CPOE is a challenging, multi-year undertaking.

AMDIS therefore recommends that inpatient CPOE be deferred for an indefinite time period because “it requires more advanced planning, building, testing, training, experience, data capture, data sharing, and decision support than many practices and hospitals can successfully achieve in the next 2-3 years.” Ironically, CCHIT makes CPOE a cornerstone of its inpatient certification.

AMDIS is warning us about the risk of EHR and CPOE system failures on a national scale. These software system failures have real life consequences. To list just one example, physicians from the Children’s Hospital of Pittsburgh reporteda highly statistically significant increase in mortality after implementation of a CCHIT-certified CPOE system.

The first step in fixing a system failure is to acknowledge that there is a problem. Although AMDIS clearly is aware that a problem exists, they continue to promote the flawed CCHIT model. I doubt, however, that their solution (try harder, you can do it!) is what most physicians and patients would choose.

What happens after 2 or more years? Where is the evidence that most physicians will ever be able to ‘jog’ or ‘run’ with EHRs built on the CCHIT model? Where is the evidence that these CCHIT-certified EHRs will be any more usable after causing 2 or more years of inefficiency, error, and potential harm to patients?

As I have written in a previous post, the CCHIT certification model is fatally flawed because it mandates hundreds of required features and functions, which take precedence over good software design.

Fortunately, the situation is not nearly as bleak as it seems. EHR technology can begin to improve patient care right away if we adopt the right model. There is no reason that it should take 2 or more years for physicians to train to use EHR technology. With well-designed, user-friendly EHR software, physicians can be up and running with core functions in 2-3 weeks, not 2-3 years.

We need to remember that Congress and the Obama administration have entrusted the national HIT Policy Committee, not CCHIT, with the mandate to shape our new HITECH policies. The national HIT Policy Committee needs to keep EHR certification rules simple and focused on standards for data, interoperability, and privacy. Keeping certification rules simple will allow physicians and hospitals to select well-designed, user-friendly EHR software that can be used meaningfully from the start.

(Note: for those readers who don’t live in the world of health information technology (HIT) acronyms, AMDIS is the sister association of the Healthcare Information Management and Systems Society (HIMSS), whose members include Siemens, GE, Allscripts, McKesson, Epic, Nextgen, and other large EHR vendors. HIMSS helped found and fund CCHIT, the Certification Commission for Health Information Technology.)

Rick Weinhaus practices clinical ophthalmology outside Boston. He trained at Harvard Medical School, the Massachusetts Eye and Ear Infirmary, and the Neuroscience Unit of the Schepens Eye Research Institute.

9 replies »

  1. Practice Fusion is one of several interesting EHR models. It is web-based (ASP) which makes it available from any office, hospital or home. It is so simple to use my students in Medical Informatics use it for EHR education with little or no training. The other aspect that is important and coincidental is that they continue to add functionality slowly so users can easily incorporate a new feature, say once a month into their brains and workflow. This is important and in contrast to high-end client server models that mandate in- house IT support and a steep learning curve.
    I have no connection to Practice Fusion and support the open-source movement as well. I would like EHRs to be affordable and easy to use and modular. Although I applaud some of the recent changes in CCHIT I am very concerned about their heavy influence by commercial vendors. I am also concerned that we not set the bar too high at this time because it will hurt adoption and science doesn’t support it. We should incrementally raise the bar as adoption climbs and when we can prove that EHRs actually affect patient outcomes, medical quality and safety…….Bob

  2. To Glen Laffel from Rick Weinhaus:
    Glen, thanks for your comment. Physicians desperately need EHR applications that are user-friendly and that can be used productively from the start.

  3. It’s hard to blame providers for being wary about ONCHIT’s seemingly aggressive implementation deadlines since many of them have experienced slow, at times painful learning curves associated with some of the popular client-server EMRs in extant.
    And it’s not surprising that AMDIS, a blood-relative of HIMSS, favors prolonging the status quo in which HIMSS-associated CCHIT certification criteria create a favorable business context for those legacy systems.
    We at Practice Fusion (http://practicefusion.com) offer a free, Web-based EMR that clinicians in many specialties have found exceptionally easy to use.
    These clinicians often begin charting the same day they sign up for it.
    Practice Fusion heartily supports ONCHIT’s directives to date. Furthermore, we hope ONCHIT sticks to its guns with respect to its implementation time frames. As more providers start using our applicaton, we suspect they may become more comfortable with these time frames.
    With so many opportunities at hand to improve the quality and cost-effectiveness of care, can we afford to delay system-wide EMR implementation any longer than we already have?
    Glenn Laffel, MD, PhD
    Sr. VP Clinical Affairs
    Practice Fusion
    Free, Web-based EMR

  4. Rick Weinhaus replies to comments:
    Healthcare Guru: I agree. From the very start of the design and development process, we need EHR software that is driven by goals and needs of patients and physicians.
    Sherry Reynolds wrote: “The National eHealth Collaborative . . . is hosting a national virtual town hall board meeting this morning at 10 am EST.”
    To Sherry: I was unable to attend the virtual meeting (I was seeing patients in the office), but I would like very much to read about or listen to the program. Is there going to be a transcript available?
    MD as Hell wrote: “I can see a neurosurgeon going to a computer to order a chest xray….NOT. The system might coerce housestaff to enter orders but real doctors won’t be doing it.”
    To MD as Hell: While I suppose it will always be the way of the world that housestaff do the bulk of order entry, more senior physicians are not averse to information technology. They just want it to work.
    iknow wrote: “The devices in current configuration . . . are dangerous because of how they promote errors. . . And there is the phenomena of cognitive dysfunction as described by Groopman.”
    To iknow: As you know, Dr. Jerry Groopman has written eloquently on how medical errors and mistakes occur, including those caused by EHRs.
    For readers not familiar with his writings, here are links to:
    (1) his book, How Doctors Think
    (2) an article in the NEJM that he co-authored with Dr. Pamela Hartzband on the pitfalls of EHRs
    (3) an article in the Wall Street Journal this March (also co-authored with Dr. Hartzband).
    Thanks to all for your comments.

  5. The devices in current configuation are meaningfully useless. To make matters worse, they are dangerous because of how they promote errors. Perfectly seasoned and wisdomed doctors have made fatal errors due to the disruption caused by the clinically unusable devices. And there is the phenomena of cognitive dysfunction as described by Groopman. We got a national experiment underway using unconsented patients as guinea pigs to the benefit of HIT vendors feeding at the trough, at taxpayers expense.

  6. Yes, I can see a neurosurgeon going to a computer to order a chest xray….NOT. The system might coerce housestaff to enter orders but real doctors won’t be doing it.
    Who is in charge of reality here?

  7. The National eHealth Collaborative which is the public private non-profit that HHS and ONC set up last year before the stimulus package (and has 9 of the policy and standards committee memebers on its board)as well as David Blumenthall from ONC is hosting a national virtual town hall board meeting this morning at 10 am EST hosted by Paul Tang the Vice Chair of the Policy Committee and the first topic will be meaningful use so weigh in.
    Here is the link to the virtual town hall meeting.
    Sherry Reynolds

  8. there you go. I have said the same thing tons of time here as well as on my blog.
    While getting a piece of the 600 billion dollar pie is more of connections, those who want to have meaningful product for meaningful use must use a high competence product development person and project mgmt person to manage the product development.
    The gap between the product development betweeen IT and the rest of the world is very wide. And based on experience in consulting with various types of groups, even the understanding is very different.
    Just likes some are from mars and some from venus.