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.