Saturday, July 24, 2010

“Meaningful Use” of EHRs: Clinically Useful or Bureaucratic Boilerplate?

People who use the word “meaningful” put my teeth of edge. “Meaningful” conveys social significance. It captures the big picture, is beyond the pale of ordinary mortals, improves the lot of humankind, or, in the case of health reform, advances the overall cause.

That is how I reacted when I heard David Blumethal, MD, national coordinator for health information technology at the Department of Health and Human Services, announce the “meaningful use” regulations for electronic health records.

Blumenthal did so with fanfare by saying “The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers.”

Here is how the WSJ Health Blog announced the news,

“The final regulations — all 864 pages of them –on what will constitute “meaningful use” of electronic medical records are now here.”

“As part of the stimulus package passed last year, up to $27 billion will be paid out by the Centers for Medicare and Medicaid Services over 10 years to providers that meet a series of requirements for EMR use.”

“ Providers will now have to meet just 14 or 15 “core” requirements dealing with EMR basics, such as being able to enter patient data and use a computer-based system to record medical orders.”

“Then they can pick an additional five objectives from a menu of ten options. Those include incorporating some lab tests results into records and providing a summary of care record for patients transferring to another facility.”

Blumenthal listed these “core set” and “menu set” of “meaningful objectives.”

Core set.

1. Record patient demographics.
2. Record vital signs.
3. Maintain up-to-date problem list of current and active diagnoses.
4. Maintain active medication lists.
5. Maintain active allergy lists.
6. Provide patients with clinical summary after each office visit.
7. On request, provide patients with electronic copy of their health information.
8. Generate and transmit prescriptions electronically.
9. Computer Provider Order Entry (CPOE) for medical orders.
10. Implement capability to electronically exchange key clinical information among providers and patient-authorized entities.
11. Implement systems to protect privacy and security of patient data into EHR.
12. Report clinicall quality measures to CMS or state

Menu set

1. Implement formulary checks.
2. Incorporate clinical laboratory test results into EHRs as structured data.
3. Generate lists of patients by specific condition for use for quality improvements, reduction of disparities, research, and outcomes.
4. Use EHR technology to identify patient-specific education resources and provide these to patients as appropriate.
5. Perform medication reconciliation between care settings.
6. Provide summary of care record for patient referral or transition to another provider setting.
7. Submit electronic immunization data to immunization registries or immunization information systems.
8. Submit electronic syndromic surveillance data to public health.

All of this, maintains Blumenthal, is necessary to improve care, assure patient safety, and reduce clinical errors. Maybe, but it also comes at a price, $30,000 to $40,000 or so, to be covered by the federal government over the next five years.

What does this all mean? What does it not mean? And how is it likely to play out among practicing doctors?

• It means that nothing is dearer and nearer to the heart of federal bureaucrats and technocrats than a “meaningful” national ubiquitous interoperable EHR system that allows doctors and hospitals to communicate with each, with patients, and with the federal government, which will have mountains of data to play with.

• It means that government will have to create new bureaucracies to make sure EHRs systems are standardized, credentialed, monitored, regulated, and implemented.

• It means that within five years, the government, through payment incentives and support systems, hopes to have most clinicians on board the EHR train.

• It does not mean, however, that clinicians will find EHRs contain useful clinical information or help communicate that information. Many clinicians tell me that current EHRs are simply data boilerplate and do not convey why a patient was referred, or help to transmit either patient-friendly, colleague-friendly, or hospital-friendly information.

• It does not mean that this transition from paper to electronics will happen without pain. Keep in mind that less than 10% of doctors and 5% of hospitals currently have fully functioning EHR systems, and many of these systems do not talk to each other; that many doctors, especially those in small groups, or solo specialists, will opt to pay the penalty for non-use of EHRs rather than install systems; that many doctors may drop Medicare and Medicaid patients rather than follow the CMS-Piper; that the $27 billion devoted to meaningful EHR use could turn into a massive federal boondoggle that neither patients or doctors will use or appreciate.

But whatever the price and inconvenience and clinical distractions, government bureaucrats and technocrats will be happy that” meaningful use” has been achieved. The only question will be: “meaningful use” for whom?

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