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Wednesday, October 5, 2011

Meaningful use: the top heavy nit picky route to possibly better health care

As part of the 2009 American Recovery and Reinvestment act (the massive stimulus package enacted at the beginning of our economic slump) doctors were offered money to start using computerized medical records for their patients insured by Medicare and Medicaid.  It was felt to be evident at that time that use of a computers to document patients' medical encounters would make communication between providers better, reduce errors, reduce redundancy of testing and procedures and overall streamline documentation. Many physicians had already started on the road to making their records digital, but government support made others take the big step.  Our office bought a very expensive computer software package from GE along with all of the hardware to support it in 2007, and by the time the stimulus package passed, we had almost adjusted to the change. We figured we would probably be well set up to be rewarded for having made this momentous change before the majority of offices.

Adjusting to an electronic health record (EHR) is not easy.  The programs for keeping such records are extremely complex, owing to the demands of privacy, legal issues, communication with other entities, drug prescribing, and the fact that most of these programs have been written over many years by programmers who no longer work for the same company and are no longer around to explain the rationale of the code they wrote, much less to fix it. The resulting products do really weird things and don't do some of the normal things that one would expect them to do.  They don't automatically check spelling, for instance. They do lag, significantly. Perfectly simple tasks make them crash, and though these bugs are fixed, they reappear whenever there is an update. Of course, my experience is with GE's product, in our office, and doesn't necessarily apply to all EHRs, but from what I hear, many of them are plagued with the same problems.

In our office in the weeks following changing from dictating or writing our notes and communicating our plans orally or in handwritten notes to doing about all of this with a computer interface, our productivity dropped precipitously. If we could see half the number of patients we had seen prior to EHR it was a good day. People, including physicians, cried, yelled, quit their jobs. It was kind of awful. We had sick people to treat, and we couldn't access their histories, write their prescriptions, and we would sit with them, powerless in front of a computer screen that would not navigate to what we needed. After a couple of years we had almost become as fast as we were before computers, but truly we have never entirely recovered. Some things are definitely better. Our notes are readable. We know what we have prescribed and when. We are reminded of schedules for vaccinations and that sort of thing. We can produce a nice looking typed note for work in a couple of minutes. But we still spend lots of time staring at a screen rather than focusing on a patient and I, personally, am still slower, even though I am quite comfortable with computers.

It was a disappointment when we learned, about a year ago, that our computer system did not qualify us for any sort of reward through the Recovery and Reinvestment Act. What was required was "meaningful use" of an electronic health record. How, we wondered, were we to make it meaningful? It sure felt meaningful to us. The cost of it was pretty meaningful: over $100,000 for the initial investment, plus more than that much in updates and lost productivity. For a bunch more money, we found out, we could have "meaningful use" and be eligible for some payments. We have embarked on that road, and a rocky one it is.

Meaningful use requires 15 "core measures" be met along with 5 out of 10 menu items. We don't have do do every one with every patient, at least not yet, but we need to make a good start. The 15 core measures are:
1. We need to enter our orders (for things like tests and consults) on the computer.
2. We need to have the drug ordering part of the program be set up to tell us about drug interactions.
3. We need to keep an updated computerized problem list for each patient.
4. We have to transmit our prescriptions electronically, those that legally can be sent that way.
5 and 6. We have to keep active medication and allergy lists.
7. We have to keep demographic information of everybody, stuff like age, sex, language and ethnicity.
8. We have to keep record of all vital signs, including the body mass index and be able to graph growth in children.
9. We need to document whether the patient smokes (age 13 and older.)
10. We need to be able to transmit clinical quality data to Medicare.
11. We need to have our EHR help us make clinical decisions about at least one condition.
12. We need to supply patients with a summary of their health record on demand, including diagnoses, allergies, medications.
13. Within 3 days of a visit, the patient needs to receive a summary of their visit, including their problems
medication changes, what referrals were made and to whom, with contact information and what followup was recommended
14. We need to be able to transmit medical records to other providers electronically.
15. Our records must be secure.
The 10 menu items, from which we can choose 5, require that we:
1. Check insurance formularies so that patients know if the prescribed drug is covered and what other options are available.
2. Have lab tests be entered in such a way that the EHR can search them and use that data in various ways (i.e. not a scanned image.)
3. Generate lists of patients with specific condition.
4. Send patients reminders for followup for certain conditions and for prevention.
5. Provide patients with electronic access to their health information within 4 days of results being available.
6. Provide patient specific education resources (I think this means things like handouts on specific diseases.)
7. Do "medication reconciliation" -- making sure that medication lists from each provider are the same.
8. Provide summaries of care when a patient is transferred from one doctor to another.
9. Electronically submit vaccination data to agencies that collect that data.
10. Submit data on diseases or syndromes observed to appropriate agencies (like Dept of Health for infectious disease outbreaks.)

Most of these requirements are both reasonable and a good idea. Some of them are a really great idea, but figuring out how to do them is going to be a bear. The main one that has me worried is the summary of the patient visit. I used to write summary letters to patients after their yearly physicals. It took forever. Not only did I need to document the visit for my chart, I had to rewrite it in a way that a patient would understand. It just about doubled the amount of time it took to document a visit. It was also a great gesture, and I'm sure the patients usually benefited from it and appreciated it. I won't deny it is a good idea, but with the slowness of computer documentation as it is now, I wonder where we will find the time. I'm pretty sure that even a good computer can't take the data from a doctor's visit and turn it into prose that will be comprehensible to a real person, so to the extent that these documents are really useful, they will have to be generated by the doctor. We are expecting a bunch of new patients to be needing primary care doctors in the next several years, associated with a shortage of these providers, which will make it nearly impossible to spend more time in documentation.

Another thing that worries me is the requirement to submit data on quality to Medicare. Some measures health care quality are deeply meaningful, for instance, is the patient happier and healthier due to a medical encounter? Unfortunately, those outcomes are difficult to measure. Instead we measure whether diabetic patients have their blood sugars below a certain, somewhat arbitrary number, or whether women over a certain age have gotten mammograms. Many of the things that we decide are good and important in health care turn out to be not good when the next study comes out. For instance, we found that vitamin E wasn't good for anything, then found that it effectively treats fatty liver in obese patients. We still disagree about how often to get mammograms on patients, and screening for prostate cancer is a hotly disputed topic.

The updates to make our computer systems jump through these hoops will make us tear out our hair, once again, and stare helplessly at poorly functioning screens while sick patient wait for our help. I still hope that one day the intelligent and computer savvy generation behind me will be hired by Medicare to produce an EHR that is as lithe, supple and fast as a cheetah and we will all use that wonderful product which will be affordable due to economies of scale. I'm waiting eagerly. If that cheetah-like EHR comes to exist, it may well improve efficiency, reduce error and lead to better communication.

So how much money is offered to physicians who choose to attempt meaningful use? If we achieve this in 2011, we get $18,000 each. In 2012 we would get 12K, in 2013, 8K, 2015 4K and then in 2015, if we haven't achieved it, we will be penalized 1% of our medicare payment, then 2% the following year.  If it takes until 2012, we only get 3 years of bonus, and so on. At most we can make $44,000 from meaningful use. That is a lot of money. It is also a drop in the bucket compared to what we will have spent in computer software, hardware and lost productivity. But that cat is out of the bag, and $44,000 is still a lot of money. The present meaningful use criteria will be replaced by stricter criteria, and it is not at all clear what those will be.

I'm not entirely sure what to think of this whole process. It seems that we are scurrying in vaguely the right direction, with better patient care as a goal, and an electronic health record as a tool to reach that goal. The way we are going about it, however, seems haphazard and destabilizing. Our aversion to truly standardizing our concepts of quality and our medical records is making these transitions much more difficult that they need to be.

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