Should There Be a Continuous Medical Education Mandate for Computerized Order Entry and Meaningful Use?

MA Physicians Must Show EHR Proficiency; the State of Massachusetts now has licensure requirements the include proficiency in the user of the Electronic Health Record (EHR).  These include understanding computerized order entry (CPOE), meaningful use, and the core EHR. 

In Florida, there are core continuous medical education (CME) requirements: HIV, medical errors (risk management) and domestic violence.  Clearly, every time a new "hot problem" arises, a new CME requirement is generated.  Next will be Ebola and vaccinations (measles, flu,?).

It is not necessarily bad to make sure that everyone is up to speed on certain topics, but what topics should be selected?  A case can be made for multiple topics both general and specialty specific.

The issue with adding the EHR under the general CME umbrella is a lack of industry standards.  Knowing how to use an EHR at a specific location does not necessarily translate into competence with other EHR applications.  Workflow is characteristically site-specific, so users ma approach the software quite differently.  You would not deal with an automated CPOE interface the same at a 120,000 visit ED as you would at a 14,000 visit ED. CPOE varies from vendor to vendor as well as the workflow for using CPOE from site to site.

 It is often essential to understand the result of a right click on the mouse  on any system. How about when going from system to system?  Will you get rodent dyslexia?  Maybe!?!  For more on the right click, read my prior blog on the Right Click Dilemma!  It is noteworthy that recruitment ads for locum tenens already include the type of system in place at the practice or hospital seeking physicians.

The second piece of the puzzle is understanding meaningful use.  Understanding meaningful use?  Seriously!?!  Remember that MU is the government's attempt to promote adoption of EHRs.  It does not, and should not, directly affect patient care.  Attention to it by practices and hospitals is ordinarily to make sure they get their share of the incentive money.  Physicians are being told, "please check these boxes, so we can be paid", but unless a physician is seeking to become an informatics subspecialist, does he or she really need to know what MU is about?

The ultimate solution is establishing national standards for the operation of any EHR, including CPOE as well as patient databases.  If every system used the same fundamental database and CPOE, the provider can figure out the various approaches used by vendors.  Remember, the Massachusetts medical society backed this issue.  HL7 has been working on it for years, and has many tools to enable EHR standardization.  Why not adopt realistic standards?  That would certainly be a meaningful, and useful thing to do.

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.