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The Case for Dropping MU Stages 2 and 3

Physicians are lining up against Meaningful Use.Dale Sanders

In a detailed letter sent this week to CMS Administrator Marilyn Tavenner and National Coordinator Karen DeSalvo, MD, the American Medical Association presented a long list of ideas to make Meaningful Use better for doctors.

The AMA warned that “unless significant changes are made to the current program and future stages,” doctors will drop out of the meaningful use program, patients will suffer as existing EHRs fail to migrate data for coordinated care, thousands of doctors will incur financial penalties, and new delivery models requiring data will be jeopardized.”

All of which is true. But the AMA didn’t go far enough.

Meaningful use is well intentioned, but like a teacher who “teaches to the test,” the program has created a byzantine system that might pass the test of meaningful use stages, but is not producing meaningful results for patients and clinicians.

A formal study published in the April 2014 issue of JAMA Internal Medicine reveals there’s no correlation between quality of care and meaningful use adherence. This study validates what common sense has told many of us for the last few years.

Meaningful Use Stage 1 was a jump-start for EMR adoption in the industry. That’s a good thing, I suppose, although meaningful use also created a false economic demand for mediocre products. It’s time to put an end to the federal meaningful use program, eliminate the costly administrative overhead of meaningful use, remove the government subsidies that also create perverse incentives, and let “survival of the fittest” play a bigger part in the process.

Let the fruits of EMR utilization go to the organizations that commit, on their own and without government incentives, to maximizing the value of their EMR investments toward quality improvement, cost reduction, and clinical efficiency.

When I arrived at Northwestern Medicine in 2005, it was clear very early that our EMRs (Epic and Cerner) were not being used in a meaningful way; this was several years before any broad discussion of meaningful use in the industry. Many Northwestern physicians were still using paper charts alongside the EMR, especially Epic in the clinics, thus creating a fragmented and dangerous medical record for patients.

Using the log and audit files in Epic and Cerner, we created an “EMR Utilization Dashboard” for each physician that also rolled up to the organizational level. The data was revealing. Outside of General Internal Medicine and a few other spotty areas, the medication list was not being used. The problem list was not being used. Order entry (CPOE) for medications, prescriptions, and tests was not being used.

Templates for documentation efficiency were not being used. Clinical alerts for best practices were not being used. Many patient encounters were not being documented in the EMR, indicating the continued use of paper records. In short, these very expensive EMRs were being used only occasionally as expensive word processors and dictation systems.

With input from all physicians, Drs. David Liebovitz, Phil Roemer, Gary Martin; and Tim Zoph and I decided to develop a simple document, describing the core principles of EMR utilization. Sarah Miller, the director of clinical applications, also played a huge part in this project.

We declared that it had to be constrained to a single page, normal spacing and font, and that we had to be data driven. It was a big success. Over the next two years, our rudimentary EMR Utilization Dashboard showed steady and significant improvement.

I showed the dashboard and the core principles to John Glaser (then at Partners HealthCare) while we were both speaking at a conference in Victoria, British Columbia. A few years later, when John went to the Office to the National Coordinator (ONC) to support David Blumenthal, John took the influence of those core principles and dashboard with him.

I’m not exactly sure what role the dashboard and those principles played in seeding the federal meaningful use program, but I suspect they had some degree of influence. By the way, we (Northwestern) offered to give the code and dashboard to the EMR vendors so that all clients could benefit, but the vendors declined.

Below are the simple but effective “Core Principles of EMR Utilization that we developed.”These principles played a huge part in the progressive value of Cerner and Epic on the Northwestern campus and laid the foundation for a relatively easy qualification of Northwestern under the federal meaningful use program (Thanks to Garima Sharma and others on the Northwestern Enterprise Data Warehouse team, which played a critical role in MU Stage 1).

Core Principles of EMR Utilization

Encounters

· All patient appointments/visits are to be documented in the EHR as an encounter.

· Visit encounters should by closed by the attending physician within 48 hours of the patient visit.

Medications

· All medication prescriptions and refills must be documented in the EHR, including those ordered in a telephone encounter.

· Medications are to be reviewed at every patient encounter, in accordance with the individual specialty’s standard of care.

· Every effort should be made to maintain a valid and complete list of patients’ current medications in the EHR, including end dates, discontinuing medications no longer being taken, and removing duplicate medication entries.

Problem Lists

· All chronic, persistent patient diagnoses or complaints should be documented on the Problem List in the EHR, with the exception of highly sensitive diagnoses such as those associated with mental health care.

· Problems should be documented using the most specific term applicable to the problem, ex: mild intermittent asthma vs. asthma.

· The Problem List should be reviewed and updated at every patient encounter, in accordance with the individual specialty’s standard of care, and problems not currently clinically relevant should be filed to history and marked as resolved.

Allergies

· Allergy lists must be actively maintained for validity and completeness for all patients, including marking as reviewed when no new allergies are reported. The allergy list must be reviewed during any encounter in which a medication is ordered.

Orders

· All patient orders must be documented in the EHR.

Progress Notes

· All patient encounters should have an accompanied progress note that appropriately documents the history, physical, and decision-making in a way that is succinct and minimizes redundant content.

· If dictating, notes must include the patient’s name and medical record number, the date of the encounter, and the attending physician’s name to ensure timely documentation.

In Basket

· Patient results and messages should be reviewed within 72 hours of receipt, and In Basket coverage should be assigned when clinicians are unable to respond within that time frame.

In the early days of EMRs, the pioneers like Intermountain Healthcare, Vanderbilt, Duke, and HealthCare Partners differentiated themselves by developing their own proprietary EMRs and then using them in a meaningful way, without any financial incentive except their own to do so.

Meaningful Use Stage 1 served a valuable purpose — it jump-started the adoption of commercially supported EMRs in an industry that needed jump-starting. Now it’s time to cancel Stage 2 and Stage 3, spend some of that money on seeds for true innovation (think DARPA for healthcare), and let survival of the fittest decide which organizations will utilize their EMRs, and subsequent data, most effectively to improve healthcare.

In addition to serving as a CIO in healthcare and the US Air Force, Dale Sanders has been one of the most influential leaders in healthcare analytics and data warehousing for the past 17 years. He currently serves as Senior Vice President for Strategy at Health Catalyst. Dale blogs about health IT at callitanything.blogspot.com.

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Dr. JimRoBertirosesandramore infoThomas Giannulli Recent comment authors
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Dr. Jim
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Dr. Jim

We adopted a Cerner system in December 2017, which replaced several discrete McKesson modules.

As far as I can tell, the major purposes of our EHR are systematic upcoding, payment farming, and excessive documentation.

When was the last time you saw a younger doctor actually do a 10-point ROS?

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SteveofCaley
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I completely agree that MU 1 had its time and place, but the complexity of MU 2 and beyond is now preventing EHR vendors from being able to focus on the EHR features providers want. We have moved away from a market-driven development process to one driven by regulation. Welcome to the machine. EHR vendors need to learn how to obey what they are told by regulations, not to offer objections. Put on the white coat, and welcome to our world! What, you think regulations exist to permit you to make a useful or profitable product? Who told you that?… Read more »

Thomas Giannulli
Guest

I completely agree that MU 1 had its time and place, but the complexity of MU 2 and beyond is now preventing EHR vendors from being able to focus on the EHR features providers want. We have moved away from a market-driven development process to one driven by regulation. Current MU2 requirements have added little new incremental value while creating a significant burden for vendors and end users. I believe that without MU, many EHR features would be similar, but there would be notable differences resulting from the focus on user feedback versus government direction. We could spend more time… Read more »

Dale Sanders
Guest

Thomas, as you know, I agree, and encourage all of us to lobby ONC and, eventually, Congress, to recognize the significant downsides to MU 2 and 3, not the least of which is what you mention– the legislation unintentionally removed the motivation and the bandwidth among EHR vendors to be creative and innovative. I met with a CIO and CMIO from a Cerner-based, academic medical center last week, well-known for their innovative use of EHRs to improve quality and efficiency of care. They achieve and exceed the spirit of MU 2 and 3 right now, under their own initiative, but… Read more »

SteveofCaley
Guest

Perhaps the VA system – which has been constructed 30 years ago and spans the entire history of EMR – should just be adopted as the gold standard, and whoever cannot approximate it in quality measures should be Federally decertified.

Dale Sanders
Guest

Meaningful Use is conceptually well-intended. As my blog mentioned, we took it upon ourselves at Northwestern to increase the value of our investment in Cerner and Epic by using those tools more “meaningfully.” But, as my dad would regularly remind me as I tried to explain my way out of a predicament, “The road to hell is paved with good intentions.” Stage 1 encouraged EMR adoption and achieved that goal, though at the expense of innovation that comes from free market competition– why take risk and be innovative when you are an EMR vendor in a market that is pounding… Read more »

SteveofCaley
Guest

And they call the tale of the Tower of Babel in the Bible a silly myth. If the goal is meaninglessly useless, how can the process be usefully meaningful? I suggest that Curly, above, most certainly rocks in his exposition of the matter.
Meaningful Use is about Shifting of Blame – Whose fault is it that there is a dead raccoon floating in the swimming pool? For there certainly seems to be one, that’s for sure.
In our culture, when given the choice between a shoddily-designed machine, and a characterologically-deranged individual, we’ll blame the individual.

Dale Sanders
Guest

@John O’Brien, I’d be glad to chat about our dashboard. How about connecting with me on LInkedIn? https://www.linkedin.com/in/dalersanders.

@John Irvine, I agree. We can work with the good folks at ONC to sponsor a better alternative. I don’t know anyone in the industry who believes the current trajectory of MU is achieving what we all hoped. It’s time for an adjustment and there’s no need for anyone to be offended or defensive about the changes. We should take pride in our ability to learn and adapt.

@BobbyGvegas
Guest

” I don’t know anyone in the industry who believes the current trajectory of MU is achieving what we all hoped.”
__

Policy ADHD?

John E. O'Brien
Guest
John E. O'Brien

Dale,

After reading your article “The Case for Dropping MU Stages 2 and 3”, I would appreciate the opportunity of presenting your dashboard to our leadership.
Keith Melton and I have been producing custom caché code (Epic) for some time now and have some applications that may be of interest to your organization as well.

Regards,
John

Dale Sanders
Guest

I can be an odd combination of naive and doggedly determined, both of which might apply to this situation. I agree that politicians being what they are, they are unlikely to pull the plug on MU because that means an admission of fault and a loss of money to the constituents that are benefitting from MU. But… I’m naive enough to believe that, with enough groundswell, we could do something, even if not outright cancellation, that would improve the Frankenstein that we created, especially if we redirected the money to better HIT uses and sustained the appeal to constituency. I’ve… Read more »

Curly Harrison, MD
Guest
Curly Harrison, MD

MU is meaningfully useless for patient care,. No, it is worse than that. It is an additional impediment to patient care.

Medical care is about ambiguity and shades of gray. EHR systems depreciate the nuances of care, and meaningful ruse destroys care processes by focusing on the irrelevant.

Rob
Guest

I was one of the leaders in the EMR arena for many years, and was initially really excited about meaningful use. Yes. I admit that with some embarrassment now. I even was part of a CDC public health grand rounds regarding meaningful use and why it would be a good thing. Over time, however, I saw what you see now: meaningful use is not a definition of using the EMR productively; it is simply another bureaucratic layer doctors must get through before they can focus on patient care. I do agree with items on your list, but the real benefit… Read more »

LeoHolmMD
Guest
LeoHolmMD

“2. Information prioritization. It’s not what is put into the system that is important, it is what you can get out of it. Most EMR systems are a jumble of useless information that hides the useful information.”

Agree strongly. I almost feel like a shadow chart needs to be developed so I can see what is important. What a mess!

Granpappy Yokum
Guest
Granpappy Yokum

“I almost feel like a shadow chart needs to be developed”

It has. It’s called “paper.”

George
Guest
George

MU is just a way to get money Rob it doesn’t stand in the way of patient care unless you bought a crappy system and fail to change your workflows.

Can you tell me a single MU measure that impaired your ability to do your job (vs how the EHR you had designed something)?

You also no longer care for medicare or medicaid patients and have a panel half the size of more docs so it sounds you are really interested in maximizing your income vs helping to solve the health care crisis