I drank the kool-aid early. We installed our first EHR in 1996 with me doing the lion’s share of pushing and pulling. While I’d ultimately turn my back on this passion, I had a number of notable accomplishments before walking down my Damascus road.
- Within a year of implementation, our practice became one of the top installations for our vendor.
- Within 2 years I was elected to the board of our user group.
- Within 4 years I was president.
- In 2003, our practice was recognized by HIMSS as one of the top primary care installations of Electronic Records.
- In subsequent years I lectured around the country (for HIMSS) extolling the benefits of EHR for both quality and efficiency of care.
- As opposed to the experience of other physicians, our practice was not only successful in our implementation, we were in the top 10% in income for our specialty.
- Our quality metrics were also routinely far above national norms.
- In 2012, I was the physician representative for CDC public health grand rounds, discussing the upcoming EHR incentive program: Meaningful Use.
- By 2013, we easily qualified for stage 1 of Meaningful Use, and I happily accepted the financial fruit of my labors.
But the final years were not, as I expected, a triumph. I became increasingly frustrated with the worsening of our EHR by the “features” needed to qualify us for MU1. I also chafed at the way most physicians were meeting this criteria: by abandoning patient-centered care and adopting a data-centered care model. Patients were given useless handouts to summarize “care,” and the data requirement was satisfied. Patient portals gave limited access to information were touted as “patient centered” care, while the product was left unused by most patients, but the data requirement was satisfied.
On top of this, my time giving attention to my patients was being squeezed out by my need to fill these data requirements. I tried as hard as possible to maintain good care in an ever shrinking amount of time, and was devastated to learn that the other physicians in my practice wanted me to stop. They were ready to throw in the towel and just focus on the data, and I was standing in the way of their “progress.”
So at the end of 2013, I left the practice I helped found, abandoned the payment system in favor of direct primary care, and bid farewell to the hamster wheel of Meaningful Use. Ironically, my top question was this:What would a medical practice look like if its central goal was good patient care? The corollary to this question was: What would a medical record look like if its only use was for patient care?
In other words: what does real meaningful use of an electronic record look like?
In this quest for “real meaningful use,” I have discovered something about the EHR. Medical records have two good uses:
- To enable communication
- To organize data
Communication is care. Patients tell about themselves so we clinicians can help them make the best medical choices possible. We communicate back to them to help them understand the care, and we also communicate with other clinicians who assist in this care. The data are used to let everyone make the most informed recommendations so that the patient can make the best decisions.
The goal of these decisions are two-fold:
- To improve their current quality of life
- To minimize their risk for the future.
People often assume “Making a Diagnosis” is the goal of care, or “Giving a Treatment,” but the diagnosis and treatment are only tools for the patient to make their life better now, and to live as long and as healthily as possible. Any diagnoses or treatments that don’t improve quality of life or decrease risk are either superfluous or unnecessarily add cost and risk.
One more thing about quality of life: spending lots of money on superfluous and unnecessary care is, by definition, a reduction in the quality of the person’s life. Furthermore, any task which takes the clinician away from focus on the patient’s quality of life and risk will inevitably increase that risk and decrease the quality of life.
My quest to accomplish these goals has been tough, as I have limited resources by which I can build a truly meaningful and useful system to give the care my patients want, but I’m making steady progress toward that goal.
It is through the eyes of this former HIMSS groupie turned computerized counterculturist that I look at the new criteria for “Meaningful Use.”
The good news is that the government has made an attempt at streamlining the goals of the project. They are to:
- Protect Patient Health Information
- Electronic Prescribing
- Clinical Decision Support
- Computerized Provider Order Entry
- Patient Electronic Access to Health Information
- Coordination of Care through Patient Engagement
- Health Information Exchange (HIE)
- Public Health and Clinical Data Registry Reporting
The objectives and their associated measures are designed to
- Align with national health care quality improvement efforts.
- Promote interoperability and health information exchange.
- Focus on the 3-part aim of reducing cost, improving access, and improving quality. (HT to David Harlow)
Furthermore, the government is not requiring information necessarily come directly through the EHR system, but instead allow the passage of data through API’s (Application Programming Interface). You tell this last fact to 98% of doctors and patients, and they do not get real excited. What’s an API? It essentially allows the medical record to be connected to patients using apps (those things you have on your smart phone, tablet, and computer).This connection would potentially be bidirectional, giving patients access to their medical data on their devices, and letting them send data to the medical record through this interface.
This reminds me of the most common words uttered at the end of a person’s life: “Watch This.” What could possibly go wrong with this?
But the targets for MU3 are not terrible: mostly focusing on the two main goals of a patient record, better communication and organizing data. I especially like the last objective, which and its 3-part aim. But there’s much in this to make me nervous.
I was, I remind you, once a believer that computerized records could greatly improve care quality and reduce cost. I spoke out in favor of Meaningful Use because I believed getting medical records computerized would ultimately allow for increased efficiency and more informed decisions. But the definition of “medical record” shifted in the process, going from a concise record of a person’s care to an enormous pile of data by which providers were judged.
This is what makes me happy I am still out of the MU3 fun club. In his blog, physician and über geek John Halamka explains:
“Providers and vendors alike were all hoping for something lean and clean. The CMS Stage 3 rule weighs in at 301 pages, but the ONC Certification rule takes the cake at 431 pages. The JASON Task Force, whose recommendations were unanimously approved by the HIT Standards and Policy Committees, recommended that ONC and CMS make an explicit trade-off: Decrease the breadth and complexity of the MU program, and in return, increase the expectations in a few key areas,such as interoperability.
The CMS MU Stage 3 rule, for the most part, has adopted this philosophy. Unfortunately, the same can’t be said for the ONC Certification rule.” (Read more here).
Translated: it not only takes 301 pages to explain the details of the simplified goals of MU for providers, the rules for computer vendors who wish to take part in this process are an additional 431 pages. I actually tried to read those 301 pages, but my ADD self screamed in horror, despite liberal consumption of triple-ritalin lattes.The bottom line for me is this:
- Is this going to make care better for patients?
- Is this going to make giving care easier for clinicians?
- Is this going to somehow break the laws of the universe, and through a massive increase in complexity somehow make care less expensive?
Somehow I think these goals are not even remotely likely to be met. The solution? I can’t say for certain for the entire system, but my care has become far more meaningful and useful for my patients since I abandoned meeting the criteria of CMS, ONC, and BCBS and focused on the only ones for which the care is truly meaningful: my patients. I know this sounds naive or pollyanna, but it really works far better than I expected. I am much happier than I expected, as are my patients.
Rob Lamberts, MD is a primary care physician practicing in the southeastern United States.
I gave up on Meaningless Use once they started requiring the Patient Portal, which none of my patients have any interest in using. My EMR has been nothing but a money pit. Our hospital installed their own EMR and it now takes me an hour to do a 5 minute laser procedure (5 minutes to do the laser and 55 minutes to document it). It burns me that the CEO of that disaster is now worth $1.8 billion of our healthcare dollars. I am going to try to find Trump on the campaign trail and beg him to repeal Obama’s ridiculous “HITECH” act and end the nightmare.
We have developed a platform which is patient centric and the documentation of the health records will hardly take anytime. It will save patient’s time as well as repetition of the tests will also reduce.
We aren’t charging any money from the Health Service Providers for this and providing a server to store their data and it costs less than $2 p.a. for the patients.
For more info, register at https://www.medicalui.com and review it.
If you are a healthcare Service provider, you can also fill up the form at the healthcare portal and we will get in touch in sometime.
I feel it solves all your problems.
Medical U I
I think it’s worth admitting that Meaningful Use did have some important positive effects, like getting many more people on EHRs and dramatically increasing e-prescribing (this last is really good for patients).
Then, somewhere, it went off the rails, and devolved into box checking and time wasting. What we need to do, then, is congratulate CMS on the new goals and objectives, but hold them to those same goals during implementation. The 3 part aim they espouse aligns with your first two questions about making care better for patients and easier for clinicians. New CMS requirements should focus on these. For instance, if they made us (really, the vendors) prove that information exchange was easier, that really would make things better.
On the other hand, they could make things worse, too, if they do it wrong. Think about the potential for difficult to implement rules about further protecting patient privacy!
One approach CMS might adopt to figure out if they are helping or hurting is time and motion studies of physicians using current EHRs vs early implementations of EHRs that are compliant with the newest MU requirements. If they see more box checking and more time on documentation, they’re moving in the wrong direction. If they see reduced time to get information and more time face-to-face with patients, they’re on the right track.
I appreciate your comments, but are you a doctor who sees patients with third party payers, especially CMS, and practices under their rules? If not, then you cannot possibly know what a nightmare that is. If you are such a physician, and are able to practice effectively and efficiently in that system, we would LOVE for you to participate in the Summit in July, and SHOW US how you do it. I have had endless people for the past 5 years (since I closed my traditional 3rdPP practice in 2010, and took a series of employed positions) TELL ME how to do my job, none of whom had actually ever done it. I have never, in my 23 years of practice, made any acceptable amount of money in private practice (<$50k/yr. I hear anywhere from $25-75k from primary care and gen surg docs I talk to – these are docs focused on patient care, not gaming the system). I do love caring for my patients in the private practice setting though. I recently reopened my office under a DPC model ($50, 75 or 100/month, depending on age, for adults. http://www.youtube.com/watch?v=bGZaRnC1wNg. I think this is promising, and the patient care experience is wonderful. Patients on medicare and medicaid pay me cash, despite having those coverages, because their doctors can't help them, they are too busy servicing their other masters. I was one of them, that's why I quit the system, I couldn't help my patients and remain in it.
Michael, I don’t support this multi-payer system, I know that it requires more work. I support single-pay, single-payer with one set of rules and one negotiated reimbursement system with no in/out network – for everyone.
But U.S. docs can opt out of all private pay by going cash only where they can write their own rules.
I also realize that these problems are mostly with PCPs, not specialists, and I support a better system for PCPs instead of our present specialist focused care. But you’d have to go to the RUC and fight your case there for a bigger part of the pie, at least for pay.
I have reduced my fees, I provide very personal care, I have an HSA w HDHP and pay my physicians and other providers w cash. Once the deductible is met my catastrophic ins plan kicks in at 100%. I walk my talk.
I pay my staff well, own a building, liability insurance for those who chose to walk in, computers, software, equipment, malpractice, and certainly never a raise in my career, only more and more burdensome regulatory oversight and mental din.
I believe in collaboration and dialogue.
Come join us and let’s talk about how to improve this situation for all.
“I walk my talk.”
You can afford an HDHP (tax supported savings portion), which works best for higher income earners, but which is the only plan premium many people can afford as there is not much savings portion they can afford for the rainy day.
“I have reduced my fees,”
Not sure why you have done that or how your type of practice allows you to do that, but what we hear from most docs is they cannot exist even on what Medicare pays – certainly not what Medicaid pays. But it appears you are doing well despite those “cuts” – so oversight costs can’t be that bad.
“more and more burdensome regulatory oversight and mental din.”
My advice is still the same, go all cash if you want off the grid.
“when the gov’t forces people to contribute to medicare”
Best deal in town, just ask contributors if they’d like to purchase private insurance well into their 60s, 70s and 80s. That is why Republicans don’t want to “fix” medicare out in the open, they’d be voted into oblivion.
I don’t like the insurance model either (I;m a single-pay guy) but at least the ACA now forces them to spend at least 80% on direct care, but despite that insurance premiums are responding to the doc/specialist oligopoly, the drug oligopoly and the device oligopoly when raising those premiums.
If you want a more affordable model then support price controls – maybe you’d be the first to step up and cut your fees for the greater good.
Maybe the PCPs should be marching on the RUC so that they can get a better cut of those specialist dollars – Occupy the AMA.
Judith and I are on the United Physicians and Surgeons of America (UPSA) committee forming this conference.
Rob, your experience and your article are outstanding. Please bring that knowledge to this national roundtable and town hall for physicians and our patients. You can speak in person, or remotely through the webcast.
I contacted you last fall, before we had a website, or much to show.
Peter, your points are well taken, but I would reply:
1.) I reopened my IM practice this Jan. on a DPC model. I believe it will succeed, but when the gov’t forces people to contribute to medicare, and when big insurance has an oligopoly corner on the market, and families send them an avg of $1250/mo. (CBS news, approx 2012. May have gone up since. Avg individ cost about half that), much deducted or contrib by their employer, so hidden to some degree, and when the oligopoly ensures that despite skyrocketing deductibles, premiums cont. to rise, there is little $ left to pay for DPC. The pending SGR “Doc fix” bill requires an NPI no. on Rx to mcare pts, and the state of Ohio just sent me notice that my Rx to mcaid pts will no longer be honored unless I participate in mcaid..
We are in this position because we have not spoken up as a group from our position of professional expertise and experience, and nothing we do in response (eg DPC) will be successful without that national physician voice. The insur and ehr lobbies will simply get laws passed nullifying our gains.
2.) Insur should have a voice in what they are paying for. They should be paying for more uncommon and high dollar events, with a commensurate premium, and not for common, lower dollar events. The insurance model does not work in the latter case. When they have a legit interest, they should have a true peer (physician in the relevant specialty) review the treating physicians notes (which should be typed and legible. Meaningful Use precludes concise notes, so that is an obstacle) and then discuss with us if they have further question. We should not be forced to re/hand write the same information onto their forms, and then wait on hold for them for 1/2 an hour, which of course there is no time for in a busy practice.
If they want to play doctor, then they need to play by doctor rules.
My thoughts, anyway.. Thank you both for yours.
Judith, nothing’s stopping docs from opting out of the medical grid – they can go cash only just as Rob has done.
As for insurance getting between docs and patients – if you were paying the bills wouldn’t you want some say into how the money is spent?
Please join this national movement to restore the patient-doctor relationship as well as restore the practice of medicine to those who actually do practice medicine. Visit our informative and interactive website. Join us in Keystone, CO for a National Grand Rounds on the State of American Medicine.
Look forward to hearing from you and hope to see you in Keystone!
Fantastic post. Should be required reading for any government affairs professionals (like me) representing qualified providers subject to these rules. Thanks for posting.
Is it true? Is it true? The HIT Kool Aid doc is taking the penalty and ignoring the meaningfully useless meaningful use?
I’ve been off of that bandwagon for over 2 years. I still think HIT is essential to give good care, but not anywhere near what is being pushed on us through the MU program. The answer to reduce car accidents is not to use horses; it’s to make safer cars and better drivers. The answer to HIT making care worse is not to use paper; it’s to make IT that focuses on good care, not billing.
“The answer to HIT making care worse is not to use paper; it’s to make IT that focuses on good care, not billing.”
Yeah, that’s Jerome Carter 101.
“The answer to HIT making care worse is not to use paper; it’s to make IT that focuses on good care, not billing.”
So is it logical to state that IT designed to function in a system that focuses on billing will inevitably make care worse?
It’s what we’ve got now. I’d say it makes care worse and is progressively lowers the bar as new data requirements come along.
Great post. What amazes me is EVERYONE agrees these systems aren’t being built nor utilized in a patient centered way however we keep being met with such resistance to re-configuring or changing them.
It seems the only way to get meaningful use or “value” is to practice outside the scope of CMS requirements, ie no Medicare, no Medicaid, no insurance.
Perry, that will work for small PCPs but how is a hospital going to abandon Medicare, Medicaid, insurance?
As well, a lot of PCPs build their business on those three income generators. I believe Rob was a well known, caring doc with a large patient following before going the club medical route.
You’re right Peter, that’s why many docs are just joining or selling out to larger entities. I just heard today of 2 family practice groups in my area which have sold out to hospitals. With Medicaid parity expiring, the Medicare payment issue up for grabs, and all the grappling required to deal with insurance companies, it’s any wonder PCPs would stay in private practice at all without totally going to direct care.
Pretty harsh calling it “club medical” given that I charge between $30-$60/month. It’s not Club Med. More like Sam’s Club than Club Med. The goal is not to have an “elite” class of medical consumers, but instead care that is worth far more than the monthly payment. So far, given the very low attrition rate, I think I have succeeded.
Ironically, the Meaningful Use program itself meets the criteria of a zombie program, an initiative that will continue to live on in an undead state for years and years, wasting taxpayer money, wasting our time and distracting us from the REALLY important work that needs to be done
The idea of “meaningful use” came because they wanted to ensure docs were using a real medical record in a meaningful way (rather than just do a word-processor and get paid for EHR use). The term now is a huge symbol of irony pointing at the way in which the program has taken doctors away from patient-centered care and into an abyss of data.
Thanks for the links. I am a fan of Dr. Carter.
See my product: http://ClinicMonkey.blogspot.com
My side gig while working for the REC.
I never liked the phrase “Meaningful Use,” even when I worked in the program (which I criticized repeatedly, notwithstanding frequently being called a “vendor shill” here by the usual unidentifiable trolls).
Begs the retort “Meaningless Use.”
“Effective Use” is what is needed. Effective from the POV of the patient, which goes right to your point.
I worry that these APIs may even make a bigger mess, from a RDBMS/data exchange/data management perspective. Hope I’m wrong there.
Jerome Carter, MD is doing some great work on these issues over at his “EHR Science” site.