The Misuse of Meaningful Use, Part II

flying cadeuciiAs a result of the determined efforts by Massachusett’s politicians, businesses, health insurance companies, hospitals, individual physicians and the Massachusetts Medical Society, nearly 100% of patients in Massachusetts now have health insurance. This is something all the healthcare players in Massachusetts can be proud of, and “universal insurance” enjoys broad public support here in Massachusetts

In an attempt to improve healthcare quality and reduce cost, Massachusetts is moving away from the “fee-for-service” system and replacing it with “physician groups” which contract with insurance companies. Most of these contracts include financial incentive/disincentive clauses about “quality” and “cost.” As a result, in Massachusetts, it is now almost impossible for a solo practitioner to obtain a contract directly with one of the state’s largest insurance companies. Almost all contracts are mediated through a local physician organization, such as an IPA, PHO or ACO.

As a result, health insurance companies now have much greater influence over the Massachusetts healthcare industry. These large insurance companies define the terms of the contract and can tell the small or medium-sized hospitals/physician contracting group their contract is a “take it or leave it” proposition. Needless to say, it is impossible for any small or medium-sized hospital/physician contracting group to refuse to accept the insurance contract when their financial viability is predicated on having access to the insurance company’s patient panel.

Originally Certified EMRs and Meaningful Use policies were created so as to provide the financially incentive to encourage primary care physicians to adopt electronic medical record programs and then use these electronic medical record programs according to specified “meaningful use” mandates. It was the hope that the appropriate use of EMRs would improve the quality or reduce the cost of healthcare. Since the program’s introduction, Meaningful Use has been expanded to almost every medical specialty and subspecialty, regardless of the appropriateness/relevance.

There has now been a fair amount of data accumulated regarding the effectiveness of electronic medical record programs. Unfortunately, most of the published data is not high quality and the majority of clinical trials are now being funded by the EMR industry. As we have seen with clinical trial sponsored by the pharmaceutical industry, only an irrational person would accept the results of a vendor sponsored EMR trial on face value.

Recently, The Office of the National Coordinator for Health Information Technology (HHS)  asked the RAND corporation to review all EMR data. RAND created the “Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use Functionalities

Unfortunately, the RAND authors appeared to have accepted the author’s conclusion at fax value. In addition, there appears to have been little or no attempt to evaluate the quality of the study and look for evidence of bias in either the design, funding or analysis of the trial. Further, the authors made the decision to collectively lump “positive” and “mixed-positive” results together in their conclusion. Clearly, this decision can only be expected to put a more positive “spin” on the overall effects which EMRs have on the quality/cost issue. As a result, I think if is likely that none of the editors of the major medical journals would reject the RAND study for publication.

In the end, the RAND report concluded that …

…that health IT, particularly those functionalities included in the Meaningful Use regulation, can improve healthcare quality and safety. The relationship between health IT and efficiency is complex and remains poorly documented or understood, particularly in terms of healthcare costs…

…much of the health IT literature still suffers from methodological and reporting problems that limit our ability to draw firm conclusions about why the intervention and/or its implementation succeeded or failed to meet expectations, and their generalizability to other contexts…

At this time, I believe it is reasonable to conclude that:

  1. Clinical decision support systems probably has a salutary effect on quality of healthcare.
  2. We do not know if “meaningful use” has a significant impact on the  quality/cost issue.
  3. EMRs may have a slightly positive effect on the quality of care but we do not know which EMR features improve the quality of healthcare. EMRs have not been shown to reduce the cost of healthcare.
  4. A large percentage of physicians are not happy with their electronic medical record program.
  5. It remains to be determined whether an ideally designed electronic medical record programs (or assemblage of HIT components) has the ability to improve the quality of healthcare delivered or reduce the total societal cost of all healthcare expenses.
  6. Physicians tend to believe that if their EMR enables them to run a more efficient practice, it will result in a salutary effect on the quality/cost issue. In fact, these two goals are not causally related. For example, I use Quicken in my office which allows me to run the financial side of my office more efficiently, but this has no effect on the cost of running the US banking industry.

In recognition of the federal government’s desire to promote electronic medical record programs, and despite the lack of “proof of efficacy,” the Massachusetts insurance industry appears to feel that they too should promote the use of EMRs/ and Meaningful Use. As a result, some of the large Massachusetts insurers are including clauses in their contract which mandate that physicians use certified EMRs according to Meaningful Use standards, and they are applying these mandates both to primary care physicians and specialists.

Given the lack of objective data about the effectiveness of EMRs, this is an outlandish overreach by the Massachusetts insurance companies which will interfere with the patient-physician interaction. As a practicing physician I am appalled to learn that the Massachusetts insurance companies seriously believe that they know how I should structure the use of my time in the exam room.

I believe that electronic medical records need to be looked at as a tool, which a physician may choose to use or not use in their practice, depending on the clinical situation.  Sometime the tool will be useful, other times it might interfere with the practice of medicine – but the only person who can make that decision is the person providing the care – the physician.

I am deeply concerned that the “EMR/MU insurance mandate” clause strike at the heart of the uniqueness of every physician-patient encounter. Essentially, the “EMR/MU insurance mandate” clause treats all physicians like vendors and tells them that they must click “this button” and “that button” every time they see a patient, even if the button click has no relevance to the clinical situation.

Massachusetts contracting entities, who are supposedly working on behalf of physicians must tell the insurance companies that the “EMR/MU insurance mandate” clause is a non-starter and “not open” for negotiations. If all the IPAs, PHOs, ACOs make the same demand, the insurance companies will have to back down. If any of these contracting entities, who are suppose to represent their physician members, fails to draw a hardline on this issue, they should be forcibly removed from their position and replaced by a person who is actually representing the best interests of physicians, the patients and the healthcare system.

Hayward K. Zwerling, M.D., FACP, FACE is an a board-certified internal medicine physician who specializes in endocrinology. He practices at the Lowell Diabetes & Endocrine Center in North Chelmsford, MA. Zwerling is also the president of ComChart Medical Software, LLC.

27 replies »

  1. And the Bayesian Ball Game plays out thus. To assemble 100 data points, one has to ACQUIRE data and RECORD data. Assume that everything’s 88% accurate. Therefore, 2/100 data points will be simply wrong.
    To mechanically sift through a body of data and correct error without any guidance, one needs to do TWO acquisitions of the same data, and then CHOOSE the best two of the three – and then RECORD the findings. That’s FOUR operations on each potentially erroneous datapoint. That sequence of operations has a 4% total error rate. (Yes, if you know enough mathematics to argue against this, you should see the futility of your own argument.) So to “Correct” a 100-piece database with 1% error rate requires 400 new operations, producing 3 or 4 spurious errors – that themselves have to be hand-verified (or put through the same automated cycle.)
    The point is, it’s far more work-intensive to check the validity of digital data than it is to just pour it into the machine. I got a mechanical warning on the electronic record for a “pregnant” patient – pregnant in 2010. There has been no confirmation that she is no longer pregnant. We have to clear her pregnancy by urine test before we can prescribe this medicine. (The presence of a four-year-old in the exam room doesn’t count.)
    Electronic data silts up into nonsense within a few short years. Shannon’s rule of entropy suggests that all information will spread out of any containment to become public knowledge within an estimatable amount of time – privacy is not time-independent. We know all this – so silence those who are too knowledgeable, the CW asserts.

  2. Well then – when it comes to a conflict between actual metabolizing carbon-based life forms, and the inhuman bureaucracy with its silicon serfs, we all put our foot down, and insist that silicon trumps carbon. If Man does not care for Machine, Man must be forced to nevertheless obey Machine.
    Sounds like a recipe for good healthcare (i.e. care of the biological human in wellness and disease.) Doesn’t it?

  3. The elephant is the list of hazards associated with digital data storage which is going to be appreciated imminently and will cause some patients to refuse this style of record format.

    First we have to assume that the data is leaky like a sieve. Secondly we need to appreciate that the data is very valuable to someone. Thirdly, we know that the data contains vital personal secrets. With these, let the imagination wander:

    The job seeker is not going to want his potential employer to know his history of back pain. The candidate for political office is not going to want his opponent to know about his ejection fraction. The spouse is not going to want the mate knowing about the products of conception found in the D&C. The patient is not going to want to receive advertisements for erectile dysfunction. The life insurance agent will like to know HgbA1c. Your son may not want you to know about his Adderall prescription. Your new business partner should know about your seizure activity. Your new match.com friend needs to know about your liver function tests and HIV.

    Blah, blah forever.

    All these are valuable data to someone and the will be available for a price.

  4. Spot on. This issue is pivotal. I’m new to the health care industry (and I use that term that in the most derogatory fashion) having come out of government weatherization and energy efficiency where we saw similar federal government stagnation around data and IT. It was enough to send me away … to health care … by accident (by husband is a chiro and needed help with insurance billing and IT) What a mess.

  5. This is a great discussion on an incredibly scary subject. As many of you know, I left the world of CPT/ICD and MU for the greener pastures of direct primary care. I’ve also dumped my MU certified EMR to instead build my own. I was once one of the biggest proponents of EMR and even spoke at the CDC (for public health grand rounds…with Farzad, actually) about meaningful use. I got my 1st check for stage 1, but then opted out of Medicare, so could not collect any more of the moolah.

    Since leaving that world I’ve discovered just how bad EMR systems have become in regard to patient care. They are geared on data collection, E/M compliance, and code generation. They are not good clinical tools, but actually get in the way of patient care by taking focus away from clinical care and toward compliance. 18 months into the process, I am much happier on the home-made EMR system which is totally focused on patient care and efficiently doing the tasks that improve their care.

    My years as an advocate of EMR, I now realize, happened as I used the existing EMR systems to streamline the process of compliance enough to allow me to still practice good patient care. The insurgence of MU made that task increasingly difficult and eventually impossible. The scary thing here is the highlighted assumption that all seem to have accepted: doctors are better off with MU certified EMR’s. They will be evasive like the tobacco industry, as the data have never shown significant benefits from EMR adoption (even pre-meaningful use).

    I agree with the commenter that speaks of this being a good way for Massachusetts to discourage doctors from practicing there. This, I assume, is why I’ve heard the state referred to as the “People’s Republic of Massachusetts.”

  6. “Maybe this is a reflection of the medical community’s perception of the real “healthcare value” of MU Stage 2, or it is a result of an unfavorable assessment of the financial benefit vs financial cost to the providers”

    Early Stage 1 attestors (2011) collected 87% of the available money thru 2013 (on the Medicare side; Medicaid is different, more complex). With only 13% of the incentive money left for the remaining breadth of the MU program, and given that participants will inevitably get held up for EHR upgrade money and have to doe workflow adjustments yet again, where’s the “incentive”? Even those who began Stage 1 in 2012 collected 2/3rd of the MU money thru 2013. Similar disincentive problem.

  7. Although it is early in the MU Stage 2 program, only 1% of providers and 3% of hospitals have attested to MU Stage 2. M

    Maybe this is a reflection of the medical community’s perception of the real “healthcare value” of MU Stage 2, or it is a result of an unfavorable assessment of the financial benefit vs financial cost to the providers or maybe it is just too early to expect providers/hospitals to attest. In my opinion, the first two possibilities are the most plausible explanation of the lack of participation. Time will tell.


  8. the solution in Massachusetts is simple.

    Every doctor should seek to become employed by the Harvard/Pilgrim Health system.

    Recently the insurance companies tried to cut Pilgrim’s reimbursements and Pilgrim blocked all the patients from their hospitals. It took less than 1 week for the insurance companies to cry uncle and pay Pilgrim whatever they wanted.

    All doctors in Mass should join Pilgrim and tell the insurance companies to screw themselves.

  9. I would be interested to know if other physician organizations either in Massachusetts or elsewhere have the same type of Meaningful Use Mandate clause in the contract between the insurance company and the local physician organization. If you’re uncomfortable publicly providing this information, feel free to email me privately at HZMD@me.com.

  10. While we’re at it, consider the wisdom of mandating secret technology as part of the clinical physician-patient relationship. Today’s mandated EHRs are secret, inacessible to peer-review, and prone to hiding their bugs behind non-disclosure agreements.

    Would we mandate physicians use statins, mammograms, or PSA tests that used secret methods? Why would we mandate the use of clinical health IT for critical decision support, quality measures, and security when these EHRs are outside the scope of physician peer review?

    Moving the practice of clinical medicine into secret software is a first-order patient safety and regulatory calamity. It doesn’t help interoperability and care coordination either. Where do we draw the line and insist on open, peer-reviewed source code?

  11. I should’ve been more clear. I agree that the federal government rules and incentives significantly distort marketplace, to the detriment of a “better solution” as well as the unfortunate creation of an entire health information technology industry which has its own agenda/political power.

    It would have been nice if the Federal Government had limited themselves to defining standard for interoperability.

  12. “I believe we need to allow the market to continue to work it’s [sic] magic, unperturbed.”

    The conundrum, though, it that of the prevailing economic incentives, which continue to be payor/government-driven (“payor/government” increasingly being one and the same). So, even with private market actors serving the space, you’re still unlikely to get HIT UX designs that are optimal for actual patient care and clinician ease/effectiveness of use. They are not truly the “customers,” as is directly the case in most other types of markets.

    Add to that the (misnomer) “interoperability” mess, well, you have a mess. Opacity + Barriers to Entry = Margin. Efficient Markets Hypothesis 101. Transparency minimizes profit, given the paradigm. It could not be otherwise. See my post “Interoperabbable update.” (You have to Google it; THCB blocks my links).

    “Productivity Treadmill” and suboptimal UX, alas, are likely to continue to rule.

  13. I think Adrian’s comment that EHRs are in the nascent stage of development, and slowly evolving is incredibly important. If physicians are locked into using a particular technology at this point it is highly likely that we will harm the patient physician relationship and the healthcare system in general, in the long run.

    I don’t know, as I said, what is the ideal design for an EMR, neither does anybody else. As surveys show a lot of physician dissatisfaction with the current incarnation of EHR design, I believe we need to allow the market to continue to work it’s magic, unperturbed.

  14. Does it really matter if EHRs are imposed on the physician-patient relationship by the physician’s employer or by the patient’s insurance company? Both are an intrusion into the practice of medicine as a profession.

    Allow me to stipulate Hayward’s conclusion that EHRs are a small win for society and don’t rise to the level of safety and effectiveness that would make it malpractice to not use a “certified” EHR.

    EHRs, at this point in time, are still evolving and it’s too soon to slow-down innovation and much too soon to neuter the influence on the employed physician by mandating their use of a technology they can’t choose because they are not the customer.

    From the physician-patient perspective, EHRs today are like so many other interventions of debatable value, where physician and patient discretion are indicated. Today’s EHRs are more like mammograms or statins or PSA tests – clinical interventions that should be optional and decided as part of the physician-patient relationship.

    Looking at EHRs from a patient’s perspective would have many important quality and cost implications. A patient-centered EHR would not have the interoperability problems of today’s silos around massively consolidated provider organizations. Patient-centered EHR would naturally coordinate care. Patient-centered EHR would increase transparency of cost and quality. Patient-centered EHRs should be more likely to keep people out of the hospital than hospital-owned EHRs. Patient-centered EHRs would focus the physician-patient relationship on the patient, and allow more rapid innovation in how to document and support diagnosis and therapy.

    It’s time for the medical profession to realize that clinical IT choice is too important to be left to the hospital, insurance, or politicians.

  15. It is clear that the law as written would prevent a large number of academic physicians and physician administrators from having a medical license in Massachusetts.

    As I said, I’m reasonably certain the situation will change before the law goes into effect.

  16. Yeah, I remember seeing that. It doesn’t take effect until 2015, right? So, there’s time to undo or mitigate it. The insurer angle is interesting. de facto “licensure,” ‘eh?

  17. The Massachusetts legislation, which requires physicians to use a certified electronic medical record programs according to Meaningful Use, as a condition of their licensure, is now undergoing revisions. It is not clear where this will end up but it is unlikely the current situation will remain unchanged.

    This change of affairs is a direct result of interventions by the Massachusetts Medical Society, which was precipitated by a blog I posted on this website…
    The EMR Use Rule: An Open Letter to Massachusetts Physicians

  18. This looks like a great way to discourage physicians from practicing in Massachusetts. Just think how long the waiting times will be.

  19. This is very interesting. I wonder how long it is going to take for the conservative state legislatures to figure this one out and start passing EHR safety reporting rules of their own, given lack of federal oversight ..
    This one and patient access to data seem like obvious places to score political points with voters. All the more reason for us to get this stuff sorted out on the national level, and pronto . .