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.

Where Has All the Interoperability Gone?

The entire meaningful use project intended to encourage provider adoption of Electronic Health Records (EHR), with the promise of easy access to patient records with two underlying goals: 1) improve the quality of health-care and 2) control rising costs.

Interoperability represents the ability of systems and organizations to work together (inter-operate).  Due to technical constraints systems often impose, the essence of interoperability in health-care has become, in essence, the need for easy, reliable exchange of information between these systems.

The EHR was supposed to interact with other EHRs to synchronize individual's medical history including tests and treatments.  Such synchronization in the US is important, as many patients wind up in different care settings.  This synchronization would give a care taker permission to all of the patient's clinical information.  This clinical data would be stored in a Health Information Exchange (HIE).  The HIE is defined as a mobilization of health-care information electronically across organizations within a region, community or hospital system. 

Although well-intended, the meaningful use program with its billions of spent dollars has further spurred the development of multiple competing health records that are by nature proprietary.  Enterprise systems, that provide the backbone of huge hospital systems are reluctant to interface with practice specific specialty "boutique" programs.  Why should these enterprise systems enable integration with boutique programs, when monopolizing their implantation over a hospital system is immensely lucrative for a vendor?  However, the reality is the boutique systems are often focused on end-user acceptance and walk-up usability, while enterprise systems--by their very nature, and especially by their hybrid, unfocused character--are unable to satisfy all end-users, if any at all.

How hard is it to interface through the HL7 standards developed for meaningful use and HIE?  According to most experts, accepting these standards takes the willingness of the participants involved.  For business reasons, many large organizations do not support standardization, and so interoperability--a functionality fully dependent on standardization-- is not an easy task.  Even if a hospital may be willing to accept the interoperability challenge, the cost of implementation is often artificially elevated by the proprietary vendors, making it prohibitive.

A related factor, referred to above with the term "hybrid", is the fantasy of a one size fits all product.  Hospital IT departments love hybrids because they theoretically means less hassle.  Their focus is less on the end-user than on avoiding potential problems for the IT department.

Hospitals, CEOs, private practitioners, politicians, and all health-care advocates should encourage their EHR vendors to allow the concept of interoperability to be enacted upon and enhanced.  You can find more information on the subject at the Center for Medical Interoperability.

Scientific Basis of "OM"

The power of meditation is explained quite well in the article, From OM to OMG: Science, Your Brain, and the Productive Powers of Meditation.  It analyzed the brain by MRI scan that is meditating to the normal active brain.  She claims it leads to better focus, less anxiety, more compassion, more creativity, better memory, less stress, and more grey matter.  The aging population especially myself can use all of these.

Meditation turns off the tumultuous, endless thoughts produced by the brain allowing one to focus with mindfulness on nothing or a particular pathway.  OM or any mantra is a sacred utterance, numinous sound, or a syllable, word, phonemes, or group of words believed by some to have psychological an spiritual power is a vehicle to achieve a meditative state.  OM is the vibration of the universe- more than a sound, but the vibration.  What's the bottom line for most people who are skeptics?  The benefits outweigh the negatives of trying it.  What if it really works?  Take advantage of easy solutions to complex problems.

This is all well and good for those who wish to spend time in a cross-legged position, or chanting, or meditating on koans, but one would eventually be led to ask, "What is brain anyway?".  What is mind?  As the Zen adept will note: if you understand, well then, things are as they are.  And if you do not understand guess what?  Things still are as they are.  Quite likely the brain exists in the physical universe very much like a smart phone on a plan; the data probably exists in multiple dimensions, and as the phone works and the brain has not stroked out, the information is there.  But does it matter that we get it?  Indeed when asked to walk the dog one should first reflect on the hope that someone's karma does not run over your dogma.

Using Shared Decision Making as a Tool

Shared decision-making is an approach where clinicians and patients communicate together using the best available evidence when faced with the task of making decisions.  This is ne of the new trends allowing patients to directly participate in their care.  The goal is to give the patient sufficient data to make an informed decision with the clinician to determine the curse of their medical care.

In the article, What is Shared Decision Making?, the author defines as a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences.

Traditionally medical care was 100% paternalistic, where Dr. Welby knew what was best in all situations.  With the tremendous growth of information available the consumer can google all the information they may or may not understand.  Even if they understand, they do not necessarily have the context to make appropriate decisions.

The provider is the person who adds the context, but it is easy for the provider to bias the process.

There are certain situations in medicine where shared decision making is inappropriate.  A patient who needs life-saving surgery or immediate cardiac care should not create an excessive dialogue.  Other not so urgent problems with multiple treatment options is another story.

There is one place where shared decision making can be used as a tool to eliminate medical-legal testing, CYA procedure, unnecessary hospitalizations, and the overuse of our extension and expensive pharmacopeia.  This will also appeal to practitioners who believe in the motto, "Trust Me" and/or "In My Experience".

Keep in mind that any action has risks.  While one might wish that the benefits of an action outweigh the risks, we all know this not to be consistently the case.  Thus any decision on which an action or the act of inaction is based has risks, and a risk/benefit ratio can be surmised.  Actualized risks have costs, the most central of which are risks to the patient and the patient's health, the secondary, and tertiary, tiers of actualized risks are litigation, blame, and social or interpersonal dispute regarding responsibility for the decision.  In traditional care models, the physician bears the secondary levels of risk; indeed in Marcus' time there was little litigation, and the risk of a questionable decision was small.  But in our current dominant medical model, there is considerable risk to the care of patients, and to shouldering the decision making process.  Hence, medical care is expensive.  Broad shoulders require huge payouts and large premiums.

In a share decision model, who would bear the risk?  Would it too be shared?  Or perhaps when the patient is a decision maker, he/she agrees to assume all the risk of the decision.  How would the elements of a negligence claim be parsed?  Duty, Breach of Duty, Proximate Cause, Damages.  Shared decision-making may be an advance, but some pieces have to be in place.  For example, standard forms upon which a doctor checks off the options, risk, recommendations, and the patient perhaps on the other side of the sheet notes his acceptance, decisions, and signature.  More forms, that's for sure.  Lots more forms.

Take advantage of the consumers' willingness to participate in their care by having informed discussion with them.  Talk with them like a family member, and give them the same advice.  The monetary savings will be astronomical and your public relation scores will sky-rocket.