A Funny Thing Happened on the Way to Meaningful Use

This July will mark the 16th anniversary of the installation of our electronic medical record.

Yup.  I am that weird.

Over the first 10-14 years of my run as doctor uber-nerd, I believed that widespread adoption of EHR would be one of main things to drive efficiency in health care.  I told anyone I could corner about our drive to improve the quality of our care, while keeping our cash-flow out of the red.  I preached the fact that it is possible for a small, privately owned practice to successfully adopt EHR while increasing revenue.  I heard people say it was only possible within a large hospital system, but saw many of those installations decrease office efficiency and quality of care.  I heard people say primary care doctors couldn’t afford EHR, while we had not only done well with our installation, but did so with one of the more expensive products at the time.  To me, it was just a matter of time before everyone finally saw that I was right.

The passage of the EHR incentive program (aka “meaningful use” criteria) was a huge validation for me: EHR was so good that the government would pay doctors to adopt it.  I figured that once docs finally could implement an EHR without threatening their financial solvency, they would all become believers like me.

But something funny happened on the way to meaningful use: I changed my mind.  No, I didn’t stop thinking that EHR was a very powerful tool that could transform care.  I didn’t pine for the days of paper charts (whatever they are).  I certainly didn’t mind it when I got the check from the government for doing something I had already done without any incentive.  What changed was my belief that government incentives could make things better. They haven’t.  In fact, they’ve made things much worse.

We first installed EHR in 1996, after we were scared by an abnormal Chest X-Ray that was missed due to our paper charting system.  We were afraid we were giving bad care for our patients, and saw computers as the solution.  Ironically, our success with our implementation hinged on our non-conformity with our EHR product’s design.  We didn’t care if we used every part of the product, instead focusing on only using things in a way that improved the care without hurting our office workflow.  Early on, we used a hybrid of paper and computers to give us the information in the proper format.  Then, once our vendor opened up the product to customization, I totally abandoned the hideous clinical content they had made, designing my own forms that maximized both quality and efficiency.

But last year, our first year in the “meaningful use” era, our focused changed in a very bad way.  We started talking more about our EHR complying to criteria than maximizing quality and efficiency.  Our vendor jumped on this bandwagon, ignoring the fact that they were stuck in a pre-internet, office-network design, and instead put all of their resources into letting their users meet “meaningful use.”  In the past, the computers were a tool we used to help our patients; with “meaningful use” they became a distraction, taking us away from a clinical focus and driving us toward proper data-gathering.

This is sadly ironic.  We were once using our computers in a meaningful way for the benefit of our patients, but now we are being pressured to abandon the patients in order to qualify for “meaningful use.”  This should come as no shock to anyone who has watched American health care over the past 20 years.  We have beaten doctors over the head with “clinical pathways,” and “evidence-based medicine,” all with a good intent: to make sure doctors gave good care.  The problem was, however, that these criteria become more important than the patients they were meant to serve.  The same is true with our payment system: designed with the initial intent of enabling patients to have access to care, but becoming a behemoth in the exam room, standing between the doctor and the patient.

So what can be done?  I don’t really know.  I still do believe that universal acceptance of EHR, coupled with patient data flowing efficiently between points of care, could improve quality and save a bus-load of money.  But I am not so sure about where we are heading.  I want to use computers for the benefit of my patients, not for the sake of compliance to the guideline de jour, or the next great government incentive program.

To paraphrase a famous political campaign motto: it’s about the patient, stupid.

So I am working to somehow comply with government guidelines (and get my incentive check so I can have a better shot at paying for four kids going through college in the next 10 years) but doing so while somehow not losing focus on the patient.  I have to say, it’s a very hard thing to do.

My dream of universal acceptance of EHR has turned sour.  I am beginning to hate the words: “meaningful use.”  I am starting to fantasize about a life without it, and maybe even a life without anybody else’s definition of what the care I give should look like.  I want to be a doctor.  I want to take care of my patients.  I want them to be the most important thing, not the other people enticing me with their big checks.  Can I stay in our system while still giving care that is meaningful?

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind)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.

22 replies »

  1. I’m an informaticist who is disturbed by the requirements of Meaningful Use. Take Medication Reconciliation, for example. In the old days, there were only paper charts, so comparing a patient’s old list from her PCP to her new one from her hospital stay was something that made perfect sense: the objective being to determine what the patient OUGHT to be taking. It also made sense to do this with problems and allergies. This is no longer the case, however.

    Enter the CCD merge.

    If your system can merge CCDs (many of them do), this “flavor” of medication reconciliation is obviated. The goal should NOT be to let MAs strike information from the patient’s record, even in the case of a misdiagnosis or a bad prescription, but that is exactly what the requirements for clinical reconciliation state. Rather than automatically merge documents and let MDs decide what should be active/inactive, we’re forcing people to jump through hoops to do something the technology is already doing for them.

    There are other “flavors” of medication reconciliation that are more important, however, but ignored by Meaningful Use. Taking medication adherence information from the patient is a process that helps providers determine not what the patient OUGHT to be taking but what the patient IS ACTUALLY taking, irrespective of the provider’s prescriptions. Decorating an active medication list with adherence information will allow providers to ask important, pointed questions to patients about why they are or are not following the provider’s prescribed regimen.

    Another “flavor” ignored by the requirements is medication reconciliation at discharge, where the patient effectively has two active medication lists, potentially in the same system (in different care settings), that must be reconciled before the patient goes home. The purpose of this “flavor” is to identify what the patient OUGHT to be taking, to keep them from doubling up on the same medications when they leave the hospital. The list should tell the patient what to STOP, what to CONTINUE, etc., and the outpatient provider should then be alerted how their medication list has changed since she last saw the patient, and it doesn’t take 2 lists to do this.

    Too often, these requirements prescribe UI that doesn’t fit with existing workflows that make more sense. Too often do the requirements illuminate the ignorance of workflows because they weren’t adequately researched. Ask a doctor about medication reconciliation, and she’ll tell you various things depending on what is important to her in her care setting. It’s not doctors’ job to identify what they do and how they do it. It’s user experience (UX) researchers’ job. Obviously, no UX researchers helped identify what people actually did and what the systems were already doing for users. Consequently, we have bloated, meaningless requirements that force users to jump through hoops for more money, all the while costing them more money and not improving patient care.

    This is a failure that must be corrected.

    EHRs are already more difficult to use than they should be, some with terrible learnability and usability that lead to bad outcomes. Moreover, the systems themselves don’t work with tablets or phones, meaning providers must change their workflows to transcribe data rather than enter it on the move, as they did with their paper charts. We have negatively impacted the cost of healthcare with these systems already, and Meaningful Use only exacerbates this.

    There is the potential not only to create things that work for phone and tablets but to create things that people LOVE. MU is unfortunately favoring only the top dogs in HIT, while the smaller competition that drives innovation drowns.

  2. Meaningful use initiatives have certainly succeeded in helping to create an awareness as to why structured data at the point of care is so critically important. WE can only improve what can be measured.
    What is unfortunate is that the approach to capturing needed, structured data is presently akin to what happened in 1914 when millions of soldiers were marched in front of machine guns to be slaughtered. The technology of war changed, but not the thinking of the system planners or the soldiers. The technology of H.I.T. and modern care teams has changed, but system planners and doctors are still in the old mind set. The result of most approaches to EHR implementation in order to achieve meaningful use will be an impending physician burn out and rejection of what is intrusively wasteful. Too many doctors are now lining up for destruction. The missiles of death are not made of lead, but are check boxes and pick lists to collect information that could be comfortably collected by others. We will soon look back on the current insanity of having doctors being the ones to collect the structured data items much in the same fashion as we now look back on how leaches were used to treat many diseases.
    The solution to successfully using the technology to achieve meaningful use is not to turn doctors into data entry trolls, enslave them after hours to EHR torments, or cause them to auto-enter blobs of garbage. It is about properly using the care team and the patient to see that needed information to improve care is put into the system for the doctor to review/edit/discuss with patients. Then, everyone wins in the struggle to meaningful usefulness.

  3. Hi, Doctor Rob! It’s my first time to read your blog and I really like how you express your thoughts into words. You are such a courageous person! As a nurse, I strongly agree that the patient’s welfare is the most important thing to consider.

  4. “You don’t just “add” EHR” or any new idea to a system. It’ll turn and bite you.”

    Sadly, the ones getting bit are the patients and the docs, not the administrators who install the systems.

  5. “physicians and staff probably aren’t ITs, and most ITs don’t know all the ins and outs of the system the software is supporting”

    Now, THERE’s an understatement.


  6. No, Bobby. I was an SQE before there was an ASQ and never bothered to join.

    What I’m saying is the front-line physicians and their suport staffs need a really good Systems Engineer, who listens to them and who understands the whole existing system. He then modifies the system to do what is needed. This may require require a couple iterations, but it doesn’t involve filling out forms with info already in the system. That’s stupid! It means that once a patient is identified, ALL the info on the patient is immediately available, including by-pass surgery 20 years ago (because it is important).

    My point is the physicians and staff probably aren’t ITs, and most ITs don’t know all the ins and outs of the system the software is supporting – they’re support personnel, not designers and systems people. You don’t just casually add new processes to old systems. You don’t just “add” EHR” or any new idea to a system. It’ll turn and bite you.

  7. Are you a member of the ASQ Software Quality Division?

    “a bunch of well meaning engineers, who think they understand what is needed”

    It’s the front-line PHYSICIANS and their support staffs who understand what’s needed. That too often gets lost, particularly in the larger inpatient settings, where HIT simply comes to be viewed as one more “IT” project.

    The medical community frrequently gets dissed for their “we’re different” complaint with respect to IT, but it’s really true to a greater degree than is credited.

    See “Medicine in Denial” by Lawrence and Lincoln Weed for the full take on the importance of HIT.

  8. As a long time Software Quality Assurance Engineer, I’ve seen this situation occur many times in my field. Someone gets a good idea for a product, and a bunch of well meaning engineers, who think they understand what is needed, jump in and put something together.

    Their solution to a problem is usually inadequate. They have not considered all the inputs, outputs and repercussions. They don’t understand how all the adjoining systems work. They don’t understand everything that is needed. They don’t have a way of evolving the product when problems (there are ALWAYS problems) occur.

    What is needed is a GOOD Systems Engineer, who can understand how the present system works, and can fit in EHR to match what you’ve already got, and then “mine” the data produced to provide better, faster, more accurate results.

    I realize these are platitudes. But don’t give up hope, or the idea. It is the way to go, you just need to understand how to evolve it. Best Wishes.

  9. ” complete assholes”

    “a rats turd”

    “find a nearby toilet instead”

    How elevating. I guess our Hall Monitor Laura Montini is off tonight.

  10. Welcome to the black and white world of politics insidiously infiltrating the gray world of health care, and then letting the perverse PR team that I firmly believe one woman poster here propagates the adage “hear the lie enough until pummeled into accepting it as truth” convince most of reasonable skeptics to believe their bull crap!

    Of course EMR had a place, but so does freedom of choice. I can’t believe how so many people here either dismiss or just ignorantly minimize the overt consequences of mandates, at least in health care. Any doctor who
    rotely believes that one standard fits all should be shamed and humiliated out of their license to practice medicine.

    To all of you who just blindly allow business models to direct health care decisions, you deserve the ultimate fates that await you. If you had any shame and humility, I wouldn’t have to write this harsh comment in the first place.

    We would have at least somewhat slowed managed care intrusions, put big pharma to some embarrassment, and showed Congress what complete assholes they really are in embracing this failed legislation as is. The AMA supported it? Who gives a rats turd what the AMA thinks! AARP? They sold their membership out years earlier anyway.

    EMR will be yet another tool for control by insidious means. Instead of sticking your clueless heads in the sand, find a nearby toilet instead.

    Mark my words, this or next Friday we will learn what the Supreme Court thought of it constitutionally. Wow, to think I have to hope 5 or more judges can help medicine, that is perverse irony!

  11. Last year I went for a colonoscopy. My Primary has been on an EHR system since 2004. The G.I. doc to whom he referred me is also on a system, one of those “Certified” ones. Nonetheless, I recall putting my Social (and a raft of other info) on at least 5 different paper forms on a clipboard while in the waiting room for the G.I. Consult. Is that the fault of the EHR technology?

  12. Best advice: Don’t buy and take the penalties.

    Your reduced productivity after purchasing these meaningfully disruptive and distracting devices far exceeds the penalty, not to mention the errors generated by the ill conceived designs.

  13. So now the futurists who told us how great meaningful use would be are extolling the virtues of non-existent ACOs. Sorry, no thanks.

  14. Fred: My concern about the ACO movement is that it is largely in the hands of hospitals and integrated delivery networks, which are not necessarily the best ones to take on the job of saving money. I’ve always felt that a lot of hospitals will go out of business with real reform, and so the job of decreasing procedures, duplicate tests, and unnecessary hospitalizations will be a bitter pill for a hospital. But they are the only ones with the financial organization to make ACO’s happen.

    I think the sad thing about all of this is that docs are not seeing EHR for what it could be: a tool to dramatically improve quality in ways that don’t hurt efficiency. We’ve accomplished this prior to MU, but have found that focus on MU has detracted from this efficiency and quality. Those who come on with MU are so focused on the criteria that they don’t see the good that can come from EHR (other than the big check from the government).

  15. I’ve given up on HIT making health more efficient or even more effective. When every medical office I enter is still tethered to a fax machine and paper forms for the patient to fill out with the same info over and over and over and when these office lose this information, either electronic or paper. We need to step back and start over. We’ve designed our clinic IT to parallel or billing/payment process. What is it EHR is to accomplish what is the process? Back to the flow chart … how does the patient flow how does the patient’s diagnosis flow?

    What do you expect, I still can’t program my VCR.

  16. Sometimes it seems that this is one big corporate welfare program mostly for the benefit of HIT vendors, in the end.

    Were I a 2011 EP Meaningful Use attestor, by 2014 I’d have gotten 87% ($38k) of the total $44k incentive money, just for being in Stage 1. I might well take a pass on Stage 2, particularly since I know that the vendors are gonna charge me for the Stage 2 upgrade and the criteria are going to be even more demanding.

    Not gonna matter to me, personally (in my current job). The RECs are only funded for Stage 1 technical assistance.

  17. Ok, Obviously I am somewhat biased. I wrote “the book” on meaningful use (shameless plug: search for that term on amazon). So I tend to think that meaningful use is a good thing.

    What does make me sad about meaningful use, it that “good actors” like Dr. Lamberts are really being punished for their early adoption. If it had not been for docs like this, none of the vendors would have gotten the practice they needed to have viable EHR products.

    My real hope for Dr. Lambert lies not with the meaningful use standards but with the ACO movement. Pay for performance should reward the subtleties that Dr. Lambert has developed expertize with: deploying EHRs for real patient outcome improvement. In that particular endeavor, meaningful use is really just the foundation. Will it work? Hell if I know. But that’s the real gamble in obamacare.


  18. I agree 100%. This is a great example of what I call “informatics dystopia”. I used to think that health IT was going to make things better, but it looks like it’s making things worse. It makes me sad not only that this is the way we are headed but also that I spent the better part of 4 years training in medical informatics.

  19. Thanks Dr. Lamberts… this is a very insightful look at how the economics of subsidies can warp the natural competitive demand for better, more efficient and more transparent technology. Great write-up.