Meaningful Use Requires Meaningless Data

Race is a medically meaningless concept.

Spare me the few tired cliches about prostate cancer, diabetes, and sarcoidosis being more common in blacks than whites, or even the slightly increased risk of ACEI cough in patients of Asian descent. We screen Jews of Ashkenazi descent for Tay Sachs without any racial labeling. All that information is readily accessible under the Family History section of the medical history. It is no more than custom which dictates the standard introductory format including age, race, and gender. It turns out I’ve blogged about this before at some length (pretty good post, actually). What is new is the advent of electronic medical records.

Much hullabaloo has been made about federal stimulus funds allocated to doctors as payments for adopting EMRs; “up to $44,000!” Here’s the problem with that figure, though, including how it breaks down (source here):

[M]aintaining [an EMR] costs multiple thousands of dollars a year. Bear in mind that they’re not talking about a lump sum payment of $44,000. It’s $18,000 the first year, $12,000 the second year, $8000 the next, $4000 the next, and then $2000, for a total of $44,000 spread over five years. FOR A SYSTEM EXPECTED TO COST AN AVERAGE OF $10,000 PER DOCTOR PER YEAR, not counting the start up costs, which run in the vicinity of $50,000. $44,000 over five years for something that will cost us $90,000 over the same period? And that’s even if they actually get around to giving out the money in the first place! According to this, in order to qualify for “meaningful use,” EMRs must be used for ePrescribing, for communicating with other EMRs like labs and hospitals, and for transmitting information on performance measures (the paternalistic proxy for “quality”) to the government.

Just because my electronic systems didn’t end up costing me anything, it turns out that even though I bill Medicare less than $25,000, I’m still eligible to apply for some of the stimulus money. So just for shits and giggles, I hooked up with a government funded entity whose stated purpose in life is to help me get that money. Cool.

I’ve had a couple of visits with them so far. It turns out that my freebie EMR has features which I hadn’t bothered using yet, mainly because they didn’t seem particularly useful in the provision of medical care — that’s what I do, remember? — to patients. One of them was a so-called “Demographics” section, right below such vital information as patient name, address, phone numbers, and birth date. This section contains three pieces of information I have to enter, one from a set of radio buttons, and two from pick lists, mechanisms that allow for the collection of what is known as “structured data” instead of just information I type into the EMR “free form”.

The first item is “Ethnicity”. There are three radio button options: Hispanic, Non-hispanic, and Unspecified (the default).

The second item is “Preferred Language”, to be selected from a pick list. I can only enter one option.

The third item is “Race”, again to be selected from a pick list. They include “African or African American”, “Asian or Asian American”, “European or Caucasion American”, plus several other basically meaningless classifications. (For example, what entry do I use for an individual from the Indian subcontinent?) Unlike “Language”, I can enter as many of these options as I wish.

What? The? F?

Aside from the language entry, which could perhaps be useful in a very large, very diverse practice, neither “Ethnicity” (limited to Hispanic or Not) nor “Race” has any possible legitimate bearing on diagnosis, treatment, or any other aspect of medical care. And yet an integral part of Government-defined “meaningful use” consists of completing this section of the medical record.

Interestingly, a stated later requirement is for me to submit information from my EMR to the government, ostensibly for what they’re currently calling “reporting purposes”.

Now, what government function uses demographic data like race and ethnicity (ie, Hispanic or not)? Would that be the tracking of, say, voting patterns? And doesn’t it seem like a handy way to collect that data, neatly sorted by address and birth date, rather than having to use the decidedly old-fashioned, up-to-a-decade-out-of-date but actually legal way of tracking that information through the census?

How Orwellian to require that “Meaningful Use” incorporate the recording of medically meaningless data.

Dinosaur MD (aka, Lucy E. Hornstein, MD) is a solo-practitioner in Family Medicine. She is also a book author (Declarations of a Dinosaur) and posts frequently at her blog, Musings of a Dinosaur, where this post first appeared.

21 replies »

  1. I was told by a EMR expert that use of an EMR will cost a practice $60,000 a year in lost productivity. And that the break even point might be age 48 years, beyond which a physician should not implement under current condiotions.
    Meaningless, meaningful use will allow you to turn a 8 line SOAP note into a 2 1/2 page termplated bullshit note. Of course everyone knows it only happened, if it’s recorded in the record.
    Of course it allows untrained clerks to assess quality of care, becuse you did 5 from column A, 4 from column B and 8 from column C or the record says you did.
    This was a big FAIL for the AMA.

  2. @Matthew Holt: Big government is going to save us, right? Good thing meaningless use was designed “by someone who thought about it a lot more than we did…” Probably the same type of person in the news for wasting $1m on a party from the GSA recently! You are a fool if you trust the government to design a health care system that anyone can count on. Just like all Big Government people, you want to hand out money that isn’t yours as incentives and then claim you have a stake in how people operate their business.

  3. @Matthew Hold: Free money? Really? Come on now, taxpayer money is not free, it is confiscated from citizens and then in this case squandered on something unnecessary. The government lures providers in with the promise of “free money” but I would wager then end up spending more money implementing “Meaningless Use” than what they gain back. I say this as an EMR Analyst who has implemented Meaningful Use at several large hospital systems and has seen all the work that goes into it.

  4. I am appalled at the post. The entire purpose of EMR, structured data and continuity of care is about improving the health of the nation; not just an individual. A clerk in a large hospital can’t say in order to do my job well, I don’t need to waste time entering data into a computer. I don’t need to track expenses because I can track them in my head. Add up these hundreds of employees and imagine them doing their own thing!

  5. I completely agree with this article, “Meaningful Use” and some of the data points collected are not the best use of a clinicians time. Some of the crap our health care system comes up with is beyond me.

  6. I think that’s an interesting point. Although EHRs are touted as a way to reduce medical errors and streamline processes, the implications for this technology are far-reaching. There’s some interesting info about the impact of EHRs and other HIT here: http://ignite.optuminsight.com/archive/the-power-of-it/ The article notes that with the ability to look at data in aggregate, metrics will become a powerful tool for improving quality of care. I’m curious to see how EHR data will be used in the coming years. The “Race” entry aside, the data could be industry-changing.

  7. Implicit in your question is the insinuation that the data in a doctor’s EHR is on no empirical value beyond those pertaining to an individual patient.

    Also implicit (and I would tend to agree) is perhaps that practicing docs are not researchers, and would have neither the time nor inclination to drill down into their data when it’s all they can do to keep the doors open.

    We have people working on that problem. We see it as an opportunity.

    I repeat: “Don’t Ask, Don’t Know.”

  8. Reposing to your comment on your blog:

    How can the original poster “strategically mine” the data from her practice on race, ethnicity, preferred language, exposure to passive smoke, etc., to improve the health care she offers her patients?

  9. This post is wrong, on the science, about race not being a scientific concept — with an asterisk. “Race,” in this case, is a proxy for a particular group being in a particular geography with intramarriage for such a long period of time that it is genetically distinct. So, for instance, while Ashkenazi Jews are not a “race,” they are genetically distinct in terms of BRCA susceptibility. Similarly, while “Asians” are not a race, there are, in fact, different racial subgroups of Han Chinese and, say, the Koreans, who trace to the Alatic group common to Mongolia.

    Because of the way racial profiling has been used in this country, we recoil at the idea of differences that are racially based.But two independent research teams, in papers published by the journal Nature in July, 2011, found a unique gene structure in African Americans compared with Europeans. The researchers would like to pursue similar research with regard to Latinos, who have a mix of European, Native American and African ancestry. In an unrelated initiative, the direct-to-consumer genetics company 23andMe is working with prestgious African American academics and others in a research project “to increase understanding of how DNA plays a role in health and wellness, especially for diseases more common in the African American community.”

  10. Mike–I can call anyone I like anything I like, and so can you. Welcome to America and the first amendment. I’m unaware about any comment deletions and I don’t do those anyway myself other than obvious spam. but if you care to tell me what got deleted I’ll look into it.

  11. And a bit ironic, don’t you think Matthew, that you deleted one of my posts that called one of your favorite contributor’s articles “rubbish” and yet here you are doing the same thing, and on your own website! I know you can do what you want, it is your site, but to so brazenly let us see who you really are….

    And I can’t help but chuckle a little as I think about how you might respond (not that you will, but I can pretty much guess your thoughts). You will either delete this post, or you will immediately try to think of “conservative” posters who are as closed minded, thus somehow in your mind justifying your own closed mindedness. God forbid that you should apologize to your readers for your duplicitous treatment of them.

  12. Unbelievable. Is this post really from the owner of this site? Wow.

    I didn’t ask the taxpayers for a dime. I’m happy to use my EHR without any incentive at all. But you are completely ______ if you think that the incentive will not be followed by a disincentive, as in a penalty for not using my EHR “meaningfully” sometime in the not so distant future. I for one plan on going for the first relatively easy $18K, unlikely to pursue it further. You can think what you want of me, but I would wager a large sum that is exactly what thousands of docs will do – collect the incentive for a year or two, then give up as the requirements become onerous. But don’t blame me – this program was designed “by someone who thought about this a whole lot more than” than I did.

    Can I have some of that Coolaid that makes me believe the data is being collected to improve patient care? It is true that the large corporate institutions you favor are able to put together systems that improve compliance to recommended treatment algorithms. (What, didn’t you know that the policies you favor will lead to larger medical corporations who are politically active and make large campaign contributions??) It is always interesting though when following the algorithm is latter found to have poorer outcomes (e.g. intensive diabetic control in the elderly). I would be interested in a link to the studies showing that patients in small practices have less quality of life and shorter life-spans – please post those links as I’m sure you have some handy.

    “Going off the grid” by using paper and charging cash. Interesting concept. Except the physicians I know of who accept only cash tend to almost always have EHRs and to use technology extensively – it’s part of what makes them able to provide personalized time-intensive care. None of the ones I know of even work in states with legalized pot. Again some links would be appreciated, or better yet, why don’t you educate yourself about “ideal medical practices” – you can start here: http://idealhealth.wikispaces.com/

    It is in the larger busier practices that adopting the EHR creates such a productivity hit. If that were not so, then why do they hire consultants? You know, the talking heads who like to think they understand healthcare better than anyone else and who pretend they have no bias as they promote systems and workflows that have not been studied for safety or improved patient outcome. Good ideas don’t require the constant drone of a used care salesman in order to be accepted.

  13. When you’re getting free money from the taxpayer (not including what they spent on that entity that is sending consultants to help you) why do you have the right to complain that the taxpayer wants some return from you?

    Even if what they want in return is only stuff that can be cross correlated with Census data. BTW that census data collection was designed by someone who thought about this a whole lot more than you did, Dinosaur…….

    And I would warrant a guess that your data, once it’s collected and compared to other, may show that you’re not practicing medicine as well as you think you are. And given that as a taxpayer or insurance policy holder, I’m paying for what you do, I might have some vague interest in knowing that fact.

    And if you dont like that scenario, by all means go off the grid, stick with paper, and charge cash only. No one is stopping you and this works well for lots of doctors–albeit mostly ones working in medical pot dispensaries.

    And BTW I know you missed that day in high school when they taught geography, but India is part of Asia

  14. Jonathan,

    The flat subscription price for an EHR/PMS, inclusive of interfaces and patient portals as needed for Meaningful Use, ranges from around $700 to well over $1000 per physician (or NP) per month. This does not include hardware, network, labor, training, productivity loss, or staff licenses (if required).
    There are no savings in physician productivity – you cannot see more patients with an EHR. There may be savings in staff labor, but they are usually offset by IT labor. There are some savings in paper products and cartridges and maybe a fax line. I have not found significant differences in cost-benefit calculations that were due solely to practice size, unless the size was big enough to command a discounted monthly fee (mostly around $1000 per year).
    $10,000 is a good middle of the road estimate for the long term. The first year costs will run you two to three times that, depending on the purchase model and ability of physicians to adapt to the EHR.

  15. $10,000 per year per physician….where did you get this cost for an EMR? Did it take into account any savings from EMR use, or only costs? Why is this number flat, instead of being higher in the first year and then diminishing as the workflow is adjusted and physicians get more comfortable using it?

    The cost-benefit calculation is not the same for all practice sizes, and of course it will depend on what EMR is purchased and used.

  16. Lots of physicians are collecting lots of data which they do not need for that $44,000. It costs money and time to collect this useless stuff. In other words, the American taxpayer will pay doctors to be less efficient, in the name of paying them to be more efficient.

    Central planning always looks like a scene from the keystone cops. Always.

    In the private sector, there is a feedback loop to discipline inefficiencies (when there is a functioning market.) By definition, government decisions are insulated from such feedback. (No, I know what you are thinking — elections do not function as feedback on granular decisions.)