Meaningful Use: RIP

Richard Gunderman goodA decade ago, electronic health records were aggressively promoted for a number of reasons.  Proponents claimed that they would facilitate the sharing of health information, reduce error rates in healthcare, increase healthcare efficiency, and lower costs.  Enthusiasts included the technology companies, consultants, and IT specialists who stood to reap substantial financial rewards from a system-wide switch to electronic records. 

Even some health professionals shared in the enthusiasm.  Compared to the three ring-binders that once held the medical records of many hospitalized patients, electronic records would reduce errors attributable to poor penmanship, improve the speed with which health professionals could access information, and serve as searchable information repositories, enabling new breakthroughs through the mining of “big data.”

To promote the transition to electronic records, the federal government launched what it called its “Meaningful Use” program, a system of financial rewards and penalties intended to ensure that patients would benefit.  Naturally, this raised an important question: if digitizing health records was such a good idea, why did the federal government need to impose penalties for health professionals who failed to adopt them?  Perhaps electronic health records were not so self-evidently beneficial as proponents suggested.

Despite the availability of $35 billion of federal funding to incentivize the adoption of this new health information technology, results have been disappointing.  For one thing, physicians, nurses, and other health professionals who rely on such systems on a daily basis reported steadily decreasing levels of satisfaction with them.  The move to electronic records has not only failed to enhance patient care but in many cases actually interfered with it.

For example, the requirement to populate the health care record with data, often motivated less by the needs of the patient than payment protocols, often draws the health professional’s attention away from patients.  Instead of increasing health professionals’ effectiveness and efficiency, too often such systems end up functioning as a distraction, keeping physicians’ and nurses’ eyes glued to a computer screen instead of the people they are caring for.

Far from increasing efficiency, many physicians find that electronic health records have slowed them down.  Faced with such tradeoffs, some simply give in, glumly allowing their gaze to shift from patients to computers.  Others extra spend extra hours on evenings and weekends attempting to tick off all the boxes.  Still others have chosen to hire “scribes,” whose job is to fill out the forms – a paradoxical situation in which enhanced efficiency has led to the hiring of additional personnel. 

A related barrier to adoption was always the substantial cost of implementation.  In the short term, the productivity of health professionals suffered, as they struggled to learn complicated new systems.  Unfortunately, many of these costs turned out not to be temporary, inflicting ongoing losses in productivity and quality of care.  The same could be said for the professional satisfaction of many health professionals, who felt as though they had been transformed into data entry specialists.

As a result, the principal point of contact between health professionals and the hospitals and health systems they work for has shifted further and further away from the needs of patients.  We are producing more healthcare data than ever before, but much of this information is both irrelevant and difficult to access.  Really relevant clinical knowledge has been watered down by data that exist purely for purposes of documentation, regulation, and payment.

One disastrous misconception underlying electronic health record systems is the notion that documenting healthcare somehow improves it.  In practice, this has led physicians and nurses to spend more and more time documenting instead of doing, without good evidence that it is helping patients.  Just because an action is documented does not make it either real or beneficial.  In many cases, the burdens of documentation have turned out to outweigh its benefits.

Given the huge start up and maintenance costs of electronic health record systems, it is not surprising that their burdens weigh disproportionately on small medical groups and hospitals.  Complex IT systems make the most sense in big organizations, in part because so many different people are involved in patient care that they cannot communicate with one another face to face.  This is not always the case, however, for smaller, more personalized care settings.

In effect, the imperative to implement electronic health records – backed by financial penalties – has helped to fuel a shift in American medicine from small to large institutions, whose greater size and complexity predisposes them to operate in a more impersonal fashion, fostering the bureaucratization of American medicine.  When health professionals who know their patients well are subjected to the same documentation requirements as those who don’t, relationship-centered care tends to suffer.

At the beginning of this year, the Obama administration announced that meaningful use would likely disappear by the end of 2016.  The problems were multiple.  First, the administration tried to propel change too far, too fast.  Second, the program was so complex that most of the people affected by it – including some of the smartest people in healthcare – did not understand it.  Third, and most seriously, the program largely ignored the perspectives of the people who actually care for patients.

If programs such as meaningful use are truly such a great idea, why aren’t they employed more widely?  Why, for example, didn’t the federal government develop a program to penalize people who failed to adopt laptop computers, the internet, or cell phones?  The answer is that truly good ideas provide sufficient impetus for their own adoption.  If an innovation stands little chance of adoption except through an arcane system of penalties, there is reason to doubt that it is truly ready for prime time.

Any time a new technology comes along, there are always hiccups.  Remember Apple’s Newton, forerunner to today’s tablet computers?  But there is a difference between a hiccup on the path to the inevitable and the kind of permanent dyspepsia that comes with being forced to live with a bad idea.  To too many health professionals, rejiggering meaningful use by another name will seem like attempting to fine tune a Rube Goldberg machine.

The pangs associated with the birth, growth and development, and now demise of meaningful use call to mind a line from Ronald Reagan, who famously said that the nine most terrifying words in the English language are, “I’m from the government, and I’m here to help.”  Based on many health professionals’ experience with the meaningful use program, these words seem to ring as true today as when Reagan first uttered them 30 years ago.

Richard Gunderman is a professor of radiology at Indiana University and a contributing writer at The Atlantic.