Meaningful Use- Rise of the “Best of Breed”?????

Is the “Meaningful Use” financial incentive actually going to end? According to article CMS Promises Meaningful Use Replacement This Year significant changes in the program will be implemented in 2016 and possibly be in effect by 2019. The goal is a more “patient-centered” output and not endless data collection.

Meaning full use was defined by the government to be

1. The use of a certified EHR in a meaningful manner.
2. The electronic exchange of health information to improve quality of health care.
3. Stimulate the adoption of EHR through financial incentives for using (e.g. not let it sit in the corner) certified EHR technology for defined elements of clinical care.

After 32 Billion Dollars expenditure in incentive money, we have a dysfunctional, non-intraoperative, and user-unfriendly national conglomeration of systems that just can’t communicate with one another.  Sounds a bit like Congress, does it not? The outcome probably should not be called a system because every product is somewhat unique and the stated goal of being able to trade information between facilities (interoperability) is no closer than it was in 2004 when then-President GW Bush put the federal government into the electronic record business.

Now, CMS has reset its sights, deciding that the new goal is not to promote adoption of EHR technology, but to pay providers for (good) outcomes that result from using such systems.  This paradigm, in CMS mind, is to replace the fee-for service paradigm. Of course! Why not!  For example, someone arrives in ventricular fibrillation and you pull out all stops to try to get the heart beating synchronously again.  Shock after shock fails.  Drugs fail. Everything fails. The patient succumbs. The outcome:  well, it is no-so-good. But you do not get paid for the powerhouse effort that you are describing on the EH R record.  No.  You write that the patient was transferred to the morgue.  Hence, the outcome deserves zero reimbursement.  Certainly much less than I you had restored cardiac rhythm and transferred to the CCU, before the patient died, and then was transferred to the morgue. Make sense?  Maybe CMS will convince hospitals to keep investing in better equipment, at least so it is ready one of the CMS administrators show up in v-fib.  Or maybe they will not, and the outcome will be vfb à morgue. 

Now, how this will be done will be interesting to watch. It will be quite challenging because certain specialties provide isolated real-time care while the traditional life-long practice provides longitudinal care. For most of the latter, the patient is still present when outcome is determined. The reconciliation of these different, and somewhat competing, paradigms will be difficult to achieve.

The Electronic Health Record, so often written about in many of our prior blogs, will need to change its fundamental character.  An emphasis on creating legally defensible documents, and an emphasis on an EHR use as a billing tool, will both be expected to come in secondary to its use as a patient-centered tool.

It’ll be nice if it works.  No skeptics here, right?  Yet, the coming evolution of the EHR may present great opportunities for focused or “Best of Breed” electronic health records that handle specific medical areas of expertise. Yes, enterprise systems will continue, but they may be constructed as user specific modules (apps) to accomplish these new goals. Think of your cell phone. These systems will have to allow “plug and play” programs or specific “apps” to give the providers the necessary support to be efficient and financially successful.

Loss of Common Sense

One of my favorite Meaningful Use Stage 3 requirements is Patient Engagement.  Really???  When does a doctor not have patient engagement?  In the morgue.  This is crazy because it really does not mean PATIENT-DOCTOR interaction...it means PATIENT-EHR interaction.

It is nuts.

Maybe patients should be reading the x-rays; interpreting the labs; discussing findings with consultants.  Who needs doctors anyway?

With the internet, WebMD, Wikipedia, the patient is way smarter than the doctor anyway.  Maybe what we need is a new form of self-care.  The patient can be BOTH patient and doctor  That will really cut costs.  And think of the medical-legal consequences.  The patient has a bad outcome and sues himself.  Whoever is coming up with this stuff needs psychotropic medications.

Trying to Put the "Meaning" in Meaningful Use

High noon for federal health records program? 2015 will be a critical year for testing the system is an eye opening article.  Arthur Allen gives a critical analysis of the whole dilemma regarding the value of an Electronic Health Record (EHR) based on the present financial incentives.

The article explains the motivation of institutions to digitalize medical records, which primarily are two: money (potentially lost) and fear (of future penalties for not abiding by the complex rules the government has created).

Meaningful Use Objectives are defined in the chart below:

1. Improve quality, safety, efficiency, and reduce health disparities
2. Engage patients and family
3. Improve care coordination, population and public health
4. Maintain privacy and security of patient health information

Ultimately, it is hoped that meaningful use compliance will result in:

1. Better clinical outcomes
2. Improved population health outcomes
3. Increased transparency and efficiency
4. Empowered individuals
5. Robust research data on health systems

The intent of MU is good, but the reality is very different.  For one thing, "meaningful" depends on perspective.  That is, for a clinical user, meaningful is a different animal than it is for administrators, and for CMS, meaningful is a wholly different species.  Providers want usable data that supports direct patient care; they dislike having to capture endless streams of data for clinical irrelevancies.

So let's ask the following- since the bottom line is that everyone wants better care, what does a clinician find meaningful while providing that care:

1. Easy access to all relevant data in a recognizable format
2. Advisory alerts when appropriate
3. Clinical decision support
4. CPOE (computerized order entry system) that is universal and not totally provider driven- (Where have all the ward clerks gone?)
5. Insert your own here "xxx"

The government is looking for data to make political, cost, and cultural changes.  One unintended result is a new industry, a new unregulated "profession", medical scribe and that has certainly raised costs.  Along the same lines, CPOE has led to more tests, which equals more costs.

My suggestion is to read the article.  It does an excellent job of presenting the issues.  Ultimately, the solution is to create a national medical database that is easily accessible, secure, and agnostic as well as transparent to all EHRs, regardless of vendor or format.  With this database and a standardized CPOE, major benefits will be obtained.  Through the retrospect-o-scope, one sees that money could have been spent on this first; then the hospitals and providers would have clamored to be first to get an EHR that makes life easier.  As it is now, there is quite a mess to sort out with respect to interoperability and usability.