By ROB LAMBERTS, MD
Quiz:
What does the term “meaningful use” mean?
a. Using something in a way that gives life purpose and leads to carefree days of glee.
b. It depends on your definition of the word “term.”
c. It is not mean. It is really nice.
d. A large number of rules created by the government to assess a practice’s use of electronic medical records so that they can spur adoption, give criteria for incentive rewards, and have physicians in a place where care can be measured.
e. Job security for those making money off of health IT.
The answer, of course is d and e.
Meaningful Use, in the eyes of many is seen as curse words, especially doctors.
Under the plan, physicians will be paid cash dollars for meeting these criteria. Here’s the payment:
- 2011 – $18,000 per physician, one-time payment
- 2012 – $12,000
- 2013 – $8,000
- 2014 – $4,000
- 2015 – $2,000
- 2016 – $0
- 2017 – 1% penalty in Medicare payments if you do not qualify.
- 2018 and beyond – 2% penalty. More criteria to qualify? More quality measures? More penalties for not meeting criteria? Stricter criteria for A1cs? Other insurance companies using the same criteria or different criteria? More government control is a definite.
So what’s the big deal? Why would doctors be against getting extra money? Here are some of the main reasons:
- They don’t want to use EMR and feel like the government is forcing them
- They think the rules are so onerous that it’s hopeless to even try
- They only like yellow charts, and the blue ones make them feel depressed
- They see that eventually non-adoption of EMR will be penalized. This makes many conclude that Meaningful Use is just a ploy for the government to cut reimbursement.
I too wish the chart was yellow, but overall I am not upset about all of this. The reason I am not upset is entirely selfish: I have been on EMR for 14 years and use a high-end product, so I will very likely be awarded the full $$ and avoid penalties. I also see this as an opportunity for physicians practicing good care to be seen as good doctors, and the bad ones to actually be penalized instead of rewarded.
You see, I have always seen EMR as much more than a computerized version of the paper chart. The true value in EMR is not that you get to type, it is that all of the information is stored in a single place, organized, and easily retrieved when needed. Using an EMR for documentation alone is like using a car to travel only as fast as you can walk. If payment is not so much based on the quality of my coding and my note-taking, but instead based on the quality of the care I give, isn’t that a good thing? Isn’t that what we should want?
No Patient Left Behind
The devil is in the details. Or, to be more accurate, the devil is in DC. The real problem with meaningful use is the fact that it is a mandate. Mandates like this – the use of testing/criteria by the government to get people to act in a certain way – have a huge flaw. This is best understood with another mandate of the government that has caused it’s own trouble: the No Child Left Behind law of 2001.
The intent of the NCLB law was to improve the quality of education in the US. It established standardized testing to:
- Set a minimum requirement for education – students cannot be passed-on to higher grades unless they pass the test.
- Held schools accountable for quality. Schools performing in the lowest range on the standardized testing would be publicly identified and penalized.
- Teachers with low student scores would be penalized as well.
But the law of unintended consequences has caught up with NCLB, with schools/teachers “gaming” the system, undo focus on test-passage over comprehensive education, and squashing of teacher creativity with fear of low test-scores. Talking to teachers and parents (as a pediatrician), there is very little love for the NCLB law.
And children pay the price of this legislation as well. I saw a child recently who is a very hard worker, a very conscientious child, and who has been able to get mainly B’s in his classes. The problem for him is that he does not take standardized tests well. Despite medication and even allowances made in the testing setting, he fails the test which covers information he has shown in the classroom that he knows. The government calls his school and teacher as the cause of his failure, but he is the one who has to be held back until he’s able to pass the test.
In the same way, making a bunch of criteria for EMR use is sure to have a slew of unintended consequences. Doctors will select EMR systems based on meaningful use criteria, not on how well they work. Doctors will select patients who can get the scores higher and discharge those who probably need the most help.
Sounds familiar.
Meaningful Meaningful Use
What should be done? The real question should be: what can an EMR do to impact patient care that would be truly meaningful? If an EMR improves the ability of the doctor to take care of the patient, that is meaningful. But if the EMR makes the doctor pay more attention to qualifying for the cash payment than to the real care of the patient, it is more meaningless use.
I use an EMR every day. I use it because it helps me give better care and makes our office run more efficiently. If we have a new process that works better by using paper, we use paper. We are not wed to the idea of using computers, we are committed to good process and excellent care. The good news for us is that doing so has made us efficient enough to increase our revenue significantly at the same time that we improve our care quality. That’s what everyone wants.
It really worries me that the imposition of these criteria on EMR will dilute my focus on patients with a focus on achieving meaningful use. This is similar to the experience of many good teachers who had to abandon more creative teaching methods to ensure better test performance. If the criteria are not right, they will do this; there is no question.
So before imposing a set of criteria to be evaluated on doctors, we need to be sure that the criteria themselves are scrutinized. For them to truly improve care and not add more burdens to medical offices, they should:
- Improve doctor/patient communication
- Make information more accessible to doctors and patients
- Capture data automatically, not necessitating extra steps that could distract from care
- Capture data so it can be used for reminders and clinical decision-making at the point of care
- Improve doctor/doctor communication (primary care to specialists and hospitals)
- Capture interventions, not just outcomes. For example, the prescription of a blood pressure medication should be rewarded, not only if the patient takes it. The ordering of a mammogram should be rewarded, not just if the patient gets it done.
- Systems should be required to “close the loop” for interventions, meaning that ordering providers should be alerted to any test, procedure, or consult results that do not come back. This is an enormous problem that frustrates many doctors and patients, increases medical liability, and causes harm. Computers are good at this kind of thing.
I am sure there are more, but my word count is getting high. The bottom line: meaningful use has to be truly meaningful.
Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.
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AWESOME
I attended the Mass eHealth Institute presentation of the final rule. I was encouraged because the final rule for the most part seemed achievable by a majority of practices – though I have my doubts about the agressive time frame.
A good tool for exchange of key clinical data is Concentrica, http://www.concentrica.com In many cases this can be a bridge to where ever the practice may land in the next 5 years. In other cases it will allow the practice to continue using their existing medical record system, and add on the required aspects of record exchange.
“WHEN this type of system either crashes or is flagrantly manipulated to screw people, then you will see the downsides”
W are already seeing this. In our hospital, whenever the EMR is down, for a system upgrade, or other housekeeping issues, our residents and the youngest Attending Physicians are lost. They do not know how to write orders on paper, or even remember the doses of common medicines. The EMR was spoonfeeding the info. So they never learnt the basics. I am hearing the same problem, from the nurses. The younger ones cannot judge what are normal and abnormal vitals, or test reports on their patients!
I will be using some of this info on my blog. I hope you dont mind.
Talking about EMRs at a site that is basically banking on it, now there is objective, unbiased commentary!
WHEN this type of system either crashes or is flagrantly manipulated to screw people, then you will see the downsides?
Careful what you wish for, and who is behind the perks.
These comments are failing to mention perhaps the most onerous component of meaningful use. Never mind just acquiring a qualifying EMR and using it–but you will also need to do your own orders–so physicians will need to order all those routine items that the staff has been ordering for decades. Works ok in a teaching environment, perhaps, but not in an old-fashioned office environment. I don’t agree with across-the-board CPOE requirements–and I have not seen any literature touting improved outcomes using CPOE in an ambulatory environment. This is lost productivity and make-work for physicians who should be using this time for something better than ordering routine lab work.
Glenn F. Marshall: You want coaching? Get off your fat ass and stop shoving food into your pie hole!! I subscribe yo the Bobby Knight school of coaching. Or do you want someone to hold your hand and look into your eyes while telling you everything will be alright if you just take this cocktail of expensive brand name petrochemicals you call medicines. That metabolic syndrome may be common, but it is all yours, tubby. Now move, move, move. Move your feet, go, go, go.
This was a nice post by someone who has been using an EMR for long enough to know the benefits of it, as well as when it doesn’t come in so handy.
While I agree with you that physicians should not be rushed into using anything by the government before they decide it is meaningful, it is also important to note that there sometimes needs to be a financial incentive involved to push adoption. What I mean by that is that judging from your example and that of many “early adopters” of EMRs, we see that there is a definite advantage of having an EMR in place. As you said, it can improve efficiency of the office, as well as improve quality of care, and in turn increase revenues.
Having said that, many physicians may still resist buying an EMR due to financial barriers and other limitations. Basically, the EMR products may be a bit out of their price range. Thus, the government reimbursement package comes in.
So, like yourself, I see the adoption of EMRs as a good thing, but the whole idea of rushing people into buying something because of certain criteria is a bit preposterous.
Dr. Lambert:
Enjoyed your article. In it you stated:
“The good news for us is that doing so has made us efficient enough to increase our revenue significantly at the same time that we improve our care quality.”
I can’t speak to “care”, but as a business man in the Health IT field, I’m amazed that more of your colleagues don’t see the connection between EMR and revenue, both top and bottom line.
When I do a return on investment scenario for even a 1 doctor practice of an EMR, the stimulus funds are the smallest part of the return. The productivity savings provide a larger and ongoing return.
Now that being said, I wouldn’t advise running out and purchasing just any EMR without due diligence. But a properly planned and implemented EMR system should provide a significant financial gain for the practice.
“Meaningful Use is just a ploy for the government to cut reimbursement”
The above statement is true and says it all. In recent years, many have embellished the rhetoric around meaningful use and health IT with a lot of meaningless nonsense.
This is all about control. Third parties (all, not just the government) simply want control over physicians’ affairs. They despise physician autonomy.
There are many more meaningful ways of improving health outcomes and reducing healthcare costs than shoving clunky EMRs down physicians’ throats. But wait, this is not really about improving health outcomes or long-term reduction in healthcare spending. It’s about control and further marginalizing physicians, a misguided agenda that will surely jeopardize patient care– at least, the high quality personalized version.
The health insurance industry has won the healthcare reform debate. Patients and physicians have been sucker punched.
By mandating the meaningful use criteria, the government has essentially killed the kind of innovative thinking in technology that can truly be disruptive and address the real deficits of our healthcare system.
LS: we are on GE, and they have been pretty forthcoming about the requirements and the few areas we need to change. I am sure there will be companies profiteering on this, but fortunately ours is not one of them. I say that as a physician “insider” with GE, given I was president of their user group and one of their “model” practices.
The truth is, if our practice does not qualify then the system is a sham.
I would not be so sure that you’re going to get that government cash. I also have been using an EMR system for years and I also use a high end product (and I pay a lot of money for it.) I am told by my EMR company that the software I use is not compliant with government requirements and that I will have to get a new system. They have no intention of bringing their existing product into compliance. They also are not sure when the upgrades will be made so it is possible that I will miss the deadlines for “meaningful use.” There are thousands of physicians in this same situation.
Meaningful use needs to be actually meaningful to patients.
I’m looking for specific measures. For example: 1) Has my own objective health status improved, e.g., better lab test results and weight loss, based on data I get and use? 2) Can I can go online with my own health record and get specific targeted suggestions on how I might do better, including alternatives and costs? 3) Has the total cost of my healthcare stayed the same year-to-year? 4) Can I schedule coordinated doctor visits, lab tests, medical imaging, and specialist visits and not have to hand-carry the results?
When I choose care providers, I’d like to know 1) Have they had an consistent and sustained increase in the percentage of favorable outcomes for common diseases under treatment? 2) Has the use of their emergency facilities for non-emergency cases decreased? 3) Has the total cost per health episode, adjusted for CPI, stayed the same or been lower? 4) Have there been a consistent and sustained decrease in the number of patients you have not treated due to lack of services or resources?
Generally, I’d like answers to these questions: 1) I have a set of chronic diseases — the common “metabolic syndrome” — and am working to improve my overall health. What sort of coaching is available? How can I track my progress? Are there more effective alternatives and, if so, what are their costs and availability from my area providers? 2) I am worried about my wife’s health. She has some chronic complaints and uses a variety of alternative treatments for the symptoms without medical advice. What can I do to help her understand the underlying causes and seek effective treatments to resolve them? 3) We will both be Medicare eligible soon. What is the optimal coverage for our healthcare, including prescription medications?
Sounds like what you want is “practical use,” as advocated by a commenter over on the EMR and HIPAA blog. It’s interesting that you use the New Child Left Behind law as a metaphor. I heard one teacher quip that the only way to achieve that goal was to slow everyone down to the slowest child’s pace of learning. It’s like when you hear about proposals that all schools be above 50th percentile in a subject: that’s impossible, since by the rules of mathematics someone has to be in the bottom 50% (even if they’re all making As).
Unintended consequences is often true no matter the law or the issue. That doesn’t mean there shouldn’t be any criteria or judgment; as you pointed out, rewarding those who are attempting better care is surely a noble goal, and we all want to feel our tax dollars are being well spent. I’ve tried to keep up with the ONC committee and workgroup meetings, and I think most of the members are trying to take these concerns to heart as they craft the meaningful use guidelines. The problem? They’re trying to work with deadline set by HITECH that at this point looks almost impossible to meet. Everyone feels rushed to get HIT/EHR adoption done as fast as possible, which isn’t the ideal way to go about making such widespread, extensive changes. I think everyone would be happier if there could be a bit more time to get this thing accomplished.