As blue-ribbon committees begin to flesh out what the vague terms of the ARRA/HITECH initiative are intended to represent, they’ve triggered quite a lot of discussion. Discussion of what does or does not constitute “Meaningful Use,” when various pieces of this definition might kick in, how many hospitals and physicians could potentially meet the 2011 criteria if they started right now and if some of the recommendations will ever be a good idea.
As I watch all of this, I can’t help feeling that the workgroups aren’t really defining “Meaningful Use,” but rather, they’re trying to define “EHR.”
You’ll recall that ARRA/HITECH sets loads of money aside to pay bonuses to physicians and hospitals (through Medicare) for achieving “Meaningful Use of a Certified EHR.”
According to HIMSS Analytics, an EHR (or Electronic Health Record) and an EMR (or Electronic Medical Record) are not the same thing. An EMR is “…the legal record created in hospitals and ambulatory environments” in electronic format, where the EHR “represents the ability to easily share medical information among stakeholders and to have a patient’s information follow him or her through the various modalities of care engaged by that individual” with data coming together from multiple EMRs.
In contrast, the venerable Wikipedia states that “For most users…the terms EHR and EMR are used interchangeably.”
The result has been that the efforts to define “Meaningful Use” have focused primarily on defining “EHR.” A half-hearted attempt has been made to indicate what metrics might be used to verify usage, but most of the energy is applied to the problem of which functional checkboxes will make the list.
In order to qualify to be an EHR, does a system need to:
- Have CPOE (Computerized Provider Order Entry)? If so, for what scope of orders?
- Be connected into some sort of Health Information Exchange (HIE) as the HIMSS Analytics definition suggests? If so, how broad does the coverage need to be to qualify? If you connect to 20% of your providers in your area does that count? Is it even meaningful for individual providers to qualify if they can’t get data from anyone else in their area?
- What’s the consumer’s role in all of this? The current proposal provides consumers with access to information on their record and encounter notes, but leaves them to their own devices on what to do with that information.
In my eyes, the current discussion has two flaws that we need to overcome to get to a successful plan:
- They are far too focused on features rather than outcomes. This causes problems in two ways:
- Energy is prioritized for checking boxes rather than accomplishing outcomes; an approach that history shows us yields a lot of checked boxes with little in the way of measurable outcomes. For example, with computers contributing to 25% of medication errors, simply checking the box isn’t working.
- It tends to quash innovation. So, for example, we require CPOE as part of the definition of what an EHR is. What happens when someone comes up with something that makes CPOE obsolete (I don’t have any plans, here, it’s just an example)? If you need to go through a regulatory change process to keep it from dramatically harming Medicare reimbursements, then it will never get off the ground. Instead, let’s state our goals for CPOE and put the goals into our Meaningful Use definition rather than this particular technology.
- The technology is being considered outside of the care delivery cycle. Can the various constituents use this technology? The answer today in many cases is no. Will they use it? What factors contribute to that adoption? The current approach suggests that placing a large pot of money in front of providers is all that is required to get them on board. I’m not certain that’s true. Furthermore, what about consumers? Does this whole process fail if they don’t adopt the technologies? To be fair, there is a small group talking about a role for usability in these discussions, but it is a still a small part of the discussion
This initial stab at a definition is just that — a start to the conversation or perhaps a vision of what the future might look like. It fails, however, at providing a path that is likely to fundamentally change the healthcare delivery system as envisioned in the bill. Getting there will take more than simply shuffling which functions are required at which times. To be successful will require returning to the approach of defining “Meaningful Use” rather than “Meaningful Functionality.”