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.

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10 replies »

  1. It is sad to hear that electronic record keeping is not working. I do agree that doctors are very impersonal now. Through personal experience I have had a doctor not make eye contact with me until he was saying goodbye. He just looked at the computer the entire time and answered text messages. I think that the problem here is more the design of the programs used to keep records and interact with patients. Technology is not perfect and there are always going to be flaws or times it does not want to work. Like I said I feel like it is not a technical issue, it is design and technical. It is easier to access records and it is an advancement but it needs to be restructured. This article is great honest feedback and delivers a challenge. The only way to make both sides happy is to redesign the electronic recording experience.

  2. I’m a bit disappointed in the general tenor of the blog and some of the responses. What we have today, partially as a result of paper records and our current practice modalities, is an error-rife system that ranks low on quality measures vs. other countries, and where 1/3 of care is waste and error. IOM tells us we kill lots of patients in hospitals. The numbers have not greatly improved. No other profession is so far behind the technology curve as medicine. So sure there are issues. Don’t just suggest that we do away with EMRs. Work to improve their use. And it is true, without interconnectivity, much of the value is lost.

    • Meaningful use as said below by another was a MISTAKE as were a lot of other government interventions that in many ways have put us in the place we are in. What do you think would have happened years ago if privately laboratories and hospitals, as the monied players, tried to interconnect their data with physicians and thereby tried to install sophisticated equipment that would do the job?

  3. The author raises some valid concerns re meaningful use and the problems with adopting EHRs in clinical practice.

    But I’m surprised that there isn’t more on the problems with the preexisting system of illegible paper notes, or more on why meaningful use and EMRs haven’t worked better.

    Does anyone really think that legibly documenting what was done in a healthcare encounter lacks value??

    Electronically documenting healthcare encounters is necessary but not sufficient, to improve the medical care of individual patients.

    Conflating this need with the need to gather data for administrative, QI, and population health imperatives is part of the problem.

  4. Now we need to repurpose hospital administrators who touted m.u. or depended on it to justify their salary.

  5. The real point of all this is that electronic records provide value when they are used for a fully integrated system, not merely to have records on a computer. Value would be created if a patient walks into an office or facility hands over an ID card which then can be read to learn all conditions, medications prescribed, tests taken in last five years, all procedures and results, allergies, etc. That could save time and money, and most likely provide more efficient and better care and lower the malpractice risks as well. Such a system could be built gradually starting with newborns and then on a gradual voluntary basis by patients. Providers who utilized such a system could better attract patients by providing less costly and more efficient and better health care.

    • You can read all my views on health care from the employer/patient perspective on my blog Quinnscommentary.com

  6. MU and digitization were policy mistakes, at least partially. Our society generally likes accountability to teach meticulous care and add thoughtfulness to people who affect others. These mistakes affected millions of people. The proponents of this mistaken policy should suffer some accountability. Indeed these same propenents preached accountability. Maybe a legislative Act could trace these people down and reduce their retirement income to twice the FPL. :=)

  7. Good points but add the fact the measures people adopt are weak and do little to drive down cost or improve quality!

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