Meaningful Meaningful Use

Quiz:  What does the term \”meaningful use\” mean?
a.  Using something in a way that gives life purpose and leads to carefree days of glee.
b.  It depends on your definition of the word \”term.\”
c.  It is not mean.  It is really nice.
d.  A large number of rules created by the government to assess a practice\’s use of electronic medical records so that they can spur adoption, give criteria for incentive rewards, and have physicians in a place where care can be measured.
e.  Job security for those making money off of health IT.

The answer, of course is d and e.

Meaningful Use, in the eyes of many is seen as curse words, especially doctors. Here are the rules:

(Click on image to see enlarged version)

Under the plan, physicians will be paid cash dollars for meeting these criteria.  Here\’s the payment:

  • 2011 – $18,000 per physician, one-time payment
  • 2012 – $12,000
  • 2013 – $8,000
  • 2014 – $4,000
  • 2015 – $2,000
  • 2016 – $0
  • 2017 – 1% penalty in Medicare payments if you do not qualify.
  • 2018 and beyond  – 2% penalty.  More criteria to qualify?  More quality measures?  More penalties for not meeting criteria?  Stricter criteria for A1cs?  Other insurance companies using the same criteria or different criteria?  More government control is a definite.

So what\’s the big deal?  Why would doctors be against getting extra money?  Here are some of the main reasons:

  1. They don\’t want to use EMR and feel like the government is forcing them
  2. They think the rules are so onerous that it\’s hopeless to even try
  3. They only like yellow charts, and the blue ones make them feel depressed
  4. They see that eventually non-adoption of EMR will be penalized.  This makes many conclude that Meaningful Use is just a ploy for the government to cut reimbursement.

I too wish the chart was yellow, but overall I am not upset about all of this.  The reason I am not upset is entirely selfish: I have been on EMR for 14 years and use a high-end product, so I will very likely be awarded the full $$ and avoid penalties.  I also see this as an opportunity for physicians practicing good care to be seen as good doctors, and the bad ones to actually be penalized instead of rewarded.

You see, I have always seen EMR as much more than a computerized version of the paper chart.  The true value in EMR is not that you get to type, it is that all of the information is stored in a single place, organized, and easily retrieved when needed.  Using an EMR for documentation alone is like using a car to travel only as fast as you can walk.  If payment is not so much based on the quality of my coding and my note-taking, but instead based on the quality of the care I give, isn\’t that a good thing?  Isn\’t that what we should want?

No Patient Left Behind

The devil is in the details.  Or, to be more accurate, the devil is in DC.  The real problem with meaningful use is the fact that it is a mandate.  Mandates like this – the use of testing/criteria by the government to get people to act in a certain way – have a huge flaw.  This is best understood with another mandate of the government that has caused it\’s own trouble: the No Child Left Behind law of 2001.

The intent of the NCLB law was to improve the quality of education in the US.  It established standardized testing to:

  1. Set a minimum requirement for education – students cannot be passed-on to higher grades unless they pass the test.
  2. Held schools accountable for quality.  Schools performing in the lowest range on the standardized testing would be publicly identified and penalized.
  3. Teachers with low student scores would be penalized as well.

But the law of unintended consequences has caught up with NCLB, with schools/teachers \”gaming\” the system, undo focus on test-passage over comprehensive education, and squashing of teacher creativity with fear of low test-scores.  Talking to teachers and parents (as a pediatrician), there is very little love for the NCLB law.

And children pay the price of this legislation as well.  I saw a child recently who is a very hard worker, a very conscientious child, and who has been able to get mainly B\’s in his classes.  The problem for him is that he does not take standardized tests well.  Despite medication and even allowances made in the testing setting, he fails the test which covers information he has shown in the classroom that he knows.  The government calls his school and teacher as the cause of his failure, but he is the one who has to be held back until he\’s able to pass the test.

In the same way, making a bunch of criteria for EMR use is sure to have a slew of unintended consequences.  Doctors will select EMR systems based on meaningful use criteria, not on how well they work.  Doctors will select patients who can get the scores higher and discharge those who probably need the most help.

Sounds familiar.

Meaningful Meaningful Use

What should be done?  The real question should be: what can an EMR do to impact patient care that would be truly meaningful?  If an EMR improves the ability of the doctor to take care of the patient, that is meaningful.  But if the EMR makes the doctor pay more attention to qualifying for the cash payment than to the real care of the patient, it is more meaningless use.

I use an EMR every day.  I use it because it helps me give better care and makes our office run more efficiently.  If we have a new process that works better by using paper, we use paper.  We are not wed to the idea of using computers, we are committed to good process and excellent care.  The good news for us is that doing so has made us efficient enough to increase our revenue significantly at the same time that we improve our care quality.  That\’s what everyone wants.

It really worries me that the imposition of these criteria on EMR will dilute my focus on patients with a focus on achieving meaningful use.  This is similar to the experience of many good teachers who had to abandon more creative teaching methods to ensure better test performance.  If the criteria are not right, they will do this; there is no question.

So before imposing a set of criteria to be evaluated on doctors, we need to be sure that the criteria themselves are scrutinized.  For them to truly improve care and not add more burdens to medical offices, they should:

  • Improve doctor/patient communication
  • Make information more accessible to doctors and patients
  • Capture data automatically, not necessitating extra steps that could distract from care
  • Capture data so it can be used for reminders and clinical decision-making at the point of care
  • Improve doctor/doctor communication (primary care to specialists and hospitals)
  • Capture interventions, not just outcomes.  For example, the prescription of a blood pressure medication should be rewarded, not only if the patient takes it.  The ordering of a mammogram should be rewarded, not just if the patient gets it done.
  • Systems should be required to \”close the loop\” for interventions, meaning that ordering providers should be alerted to any test, procedure, or consult results that do not come back.  This is an enormous problem that frustrates many doctors and patients, increases medical liability, and causes harm.  Computers are good at this kind of thing.

I am sure there are more, but my word count is getting high.  The bottom line:  meaningful use has to be truly meaningful.

15 thoughts on “Meaningful Meaningful Use”

  1. Where in any of the goals or outcomes is: “patient feels better”? I think that's why most of us see a doctor when we do; we want to feel better. Why isn't that one of the goals?

  2. Another reason some of us aren't thrilled with mandatory EHR is that within few years, despite what looks like a big monetary incentive, many of us will then be paying large sums of money to use and maintain these systems. For a small practice like mine, it will be tough.

  3. Dr. Rob,

    Great blog this AM and article in Physician's Practice June 2010. As an administrator of a medical practice, I implemented an EMR in 2007 and learned most of the lessons you speak of first hand. We had many internal workflow and patient care issues that were solved by implementing the EMR, but without the clear goals to acheive and a driving strategic plan and vision, I know our practice would not have had a successful implementation. Also, I had past experience in a vendor organization, therefore, I completely understood the role of the vendor and our role in the process. Keep up the fine work of educating.

  4. We started on EMR with 2 physicians and no incentives. Now we are up to 8 providers and have a much lower overhead and higher take-home than most physicians. There is a hump to get over, but if done right, EMR works to improve how practices work. Really. The whole point of the HITECH incentives was to get docs a cushion for when they adopt.

  5. Paper charts, 43% overhead, work four days/week, income top 20% for family docs. Will EMRs improve that?

  6. I do the same and earn the same, yet I have powerful disease management tools using the data, we routinely do queries on the database for diabetics who have not been in the office for more than 6 months, etc. we were NCQA certified for diabetes with about 20 minutes of work on our part, and lots more advantages for my staff (never having to look for a chart, etc).

    Truthfully, I think you are an ideal EMR doc, as you are obviously focused on getting the system to work well, which you have despite the big disadvantage of paper charts. EMR is a very good organizational tool and is good to streamline processes, but only if the people use the tool properly. You have no motivation financially, but I bet I can get more data faster when I am sitting in the exam room. When I send patients to a specialist, our referral coordinator is usually working on it before I leave the room.

  7. Overall, I agree with your comments. On NCLB, I agree that the implementation is terrible, but your example (student knows the subject but can't pass the test) it is possible to do the testing with a one-on-one proctor to keep the student on task, it's just that most schools won't spend the money for their special needs students.

    As to your statement: “Capture interventions, not just outcomes. For example, the prescription of a blood pressure medication should be rewarded, not only if the patient takes it. The ordering of a mammogram should be rewarded, not just if the patient gets it done” I must disagree. Part of good patient care is emphasizing the importance of medications and tests, and following up to make sure the patient is taking the meds or getting the tests done and if not, finding the reasons the pt is non-compliant and identifying (with pt involvement) acceptable alternatives.

  8. Good post! Uncle Sam is looking at Meaningful Use as a template/process to ultimately save money. However, the gov't has never been good at saving money and we now have the beginnings of another huge bueracracy. Do you have any insight on the timelines for Meaningful Use? I think there is some issues with 4-5 of the criteria and the gov't has not officially defined Meaningful Use. Will the 2011 timelines be pushed back if the official criteria are not released soon?

  9. I think capturing both is important. Patient compliance is partly doctor-directed, but not entirely. What you don't want is to give docs an incentive to discharge difficult patients.

    Regarding that kid, actually the parents totally went to bat and got the best help the school could offer, but the rules don't stretch indefinitely.

  10. A small correction: “undo” should be “undue”.

    Thanks for a very interesting post in a great blog. I've enjoyed reading over the past month or so.

  11. Peggy Polaneczky, MD

    I'll tell you what meaningful use should be measured in – efficiency of the EMR. At this point, there is so much cutting and pasting, repetition, meaningless documentation to be sure payment is optimized but just try to wade through the chart of a patient who has been in the system for more than a year seeing multiple providers and you realize just how big a mess we're creating.

    That said, I still, like you, love my EMR. Just tired of all the work arounds I've had to come up with to make it work for me.

    Great post.

  12. […] of attention like I once was; I am now attending to actually learn things.  The whole “meaningful use” requirements are breathing down doctors’ necks, even doctors who have used EMR since […]

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