This July will mark the 16th anniversary of the installation of our electronic medical record.
Yup. I am that weird.
Over the first 10-14 years of my run as doctor uber-nerd, I believed that widespread adoption of EHR would be one of main things to drive efficiency in health care. I told anyone I could corner about our drive to improve the quality of our care, while keeping our cash-flow out of the red. I preached the fact that it is possible for a small, privately owned practice to successfully adopt EHR while increasing revenue. I heard people say it was only possible within a large hospital system, but saw many of those installations decrease office efficiency and quality of care. I heard people say primary care doctors couldn\’t afford EHR, while we had not only done well with our installation, but did so with one of the more expensive products at the time. To me, it was just a matter of time before everyone finally saw that I was right.
The passage of the EHR incentive program (aka \”meaningful use\” criteria) was a huge validation for me: EHR was so good that the government would pay doctors to adopt it. I figured that once docs finally could implement an EHR without threatening their financial solvency, they would all become believers like me.
But something funny happened on the way to meaningful use: I changed my mind. No, I didn\’t stop thinking that EHR was a very powerful tool that could transform care. I didn\’t pine for the days of paper charts (whatever they are). I certainly didn\’t mind it when I got the check from the government for doing something I had already done without any incentive. What changed was my belief that government incentives could make things better. They haven\’t. In fact, they\’ve made things much worse.
We first installed EHR in 1996, after we were scared by an abnormal Chest X-Ray that was missed due to our paper charting system. We were afraid we were giving bad care for our patients, and saw computers as the solution. Ironically, our success with our implementation hinged on our non-conformity with our EHR product\’s design. We didn\’t care if we used every part of the product, instead focusing on only using things in a way that improved the care without hurting our office workflow. Early on, we used a hybrid of paper and computers to give us the information in the proper format. Then, once our vendor opened up the product to customization, I totally abandoned the hideous clinical content they had made, designing my own forms that maximized both quality and efficiency.
But last year, our first year in the \”meaningful use\” era, our focused changed in a very bad way. We started talking more about our EHR complying to criteria than maximizing quality and efficiency. Our vendor jumped on this bandwagon, ignoring the fact that they were stuck in a pre-internet, office-network design, and instead put all of their resources into letting their users meet \”meaningful use.\” In the past, the computers were a tool we used to help our patients; with \”meaningful use\” they became a distraction, taking us away from a clinical focus and driving us toward proper data-gathering.
This is sadly ironic. We were once using our computers in a meaningful way for the benefit of our patients, but now we are being pressured to abandon the patients in order to qualify for \”meaningful use.\” This should come as no shock to anyone who has watched American health care over the past 20 years. We have beaten doctors over the head with \”clinical pathways,\” and \”evidence-based medicine,\” all with a good intent: to make sure doctors gave good care. The problem was, however, that these criteria become more important than the patients they were meant to serve. The same is true with our payment system: designed with the initial intent of enabling patients to have access to care, but becoming a behemoth in the exam room, standing between the doctor and the patient.
So what can be done? I don\’t really know. I still do believe that universal acceptance of EHR, coupled with patient data flowing efficiently between points of care, could improve quality and save a bus-load of money. But I am not so sure about where we are heading. I want to use computers for the benefit of my patients, not for the sake of compliance to the guideline de jour, or the next great government incentive program.
To paraphrase a famous political campaign motto: it\’s about the patient, stupid.
So I am working to somehow comply with government guidelines (and get my incentive check so I can have a better shot at paying for four kids going through college in the next 10 years) but doing so while somehow not losing focus on the patient. I have to say, it\’s a very hard thing to do.
My dream of universal acceptance of EHR has turned sour. I am beginning to hate the words: \”meaningful use.\” I am starting to fantasize about a life without it, and maybe even a life without anybody else\’s definition of what the care I give should look like. I want to be a doctor. I want to take care of my patients. I want them to be the most important thing, not the other people enticing me with their big checks. Can I stay in our system while still giving care that is meaningful?
9 thoughts on “A Funny thing Happened on the way to Meaningful Use”
So true and so frustrating, Bob.
Easy does it. I find that the health care providers challenges are fierce but we have a sure and strong spirit in us that will take us through. I am struggling to keep humble and rested so that I can be healthy enough to be a micro-mini part of the answer each day. Doing the next little right thing will add up to a lifetime of deceptively small but precious victories. Yesterday I gave in to some fear and doubt and it was not pretty when it led to anger. Today, I am up early to have time with God to re-set my attitude.
I will have to cite this on my independent REC blog. I work in the “Meaningful Use” program, and I too have come to hate the phrase. And, I have taken flack from one of my Sups for my Bad Attitude, not being enough of a dutiful Kool-Air Drinker.
Your post is now cited on my blog.
I put in my info; I’m hoping I’ll get my check soon. My EHR tells me that what I’ve done is meaningful, although some of the numbers collected for me I still don’t understand. I find I’m backsliding on one of the things I think could be most truly meaningful, the clinical summaries for my patients, because it takes too much time and effort during a visit to write in the things that will actually be helpful to the patient. I could simply use the default form of my EHR and give them a bunch information that is meaningless to both them and me, but to make it work the way I think it should work – that is not easy. I feel sad when I think that everybody’s jumping through hoops to make more money for EHR companies and consultants rather than making the healthcare non-system better.
Rob, your story is such a poignant, and sad, one. This so reminds me of what teachers have been going through. They used to teach to teach. Then came along standardized tests and then sticks and carrots for hitting targets. Now, they first teach to the test, and some still get the old-fashioned teaching in. Are we in the same space now in health care?
Sorry for taking a bit to get back to this (the emails seem to be going to spam). I look at this is “no patient left behind,” with the same end-result as “no child left behind” that you describe. It seems standardization is a good thing, and it may be in some cases, but your goal should be outcomes (both for health care and for education), and leave the route of getting to better outcomes to teachers and doctors. This approach stifles innovation and doesn’t fix things at all.
Whilst I feel your pain, consider yourself lucky compared to some other countries where rather than try and define meaningful use of the EHR the government has tried to actually design and mandate their own version of the EHR. Whilst some aspects of the US meaningful use rules may be counter intuitive to many of us as physician the population health goals and consumer empowerment goals further down the line will help transform the healthcare system.
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