Joel Diamond 1/6/10

On Meaningful Use

“The word ‘meaningful’ when used today is nearly always meaningless.” -Paul Johnson

Seems like everyone today is searching for a meaningful experience. Everything from bowel movements to watching a television series needs to be “meaningful”. It should therefore come as no surprise that the meaningful adoption of HIT should also be debated so passionately.

I just plowed through the 500+ page Department of Health and Human Services Electronic Health Record Incentive Program that is intended to define meaningful use and found the exercise to be quite… meaningful.

I know that many of you are cynical about the topic, but think about it. It really makes sense. The government just can’t rationalize massive financial payouts without a precise measure of benefit. OK, I guess there are a few exceptions… Wall Street financial firms for one, but never mind that… and oh yeah, I guess the pharmaceutical industry essentially getting a blank check from Medicare, but ignore that too. It only makes things more confusing.

In Sections 1848 (o)(2)(A) and 1886(n)(3) of the Act, the Congress specified three types of requirements for meaningful use: (1) use of certified EHR technology in a meaningful manner (for example, electronic prescribing); (2) that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and (3) that, in using certified EHR technology, the provider submits to the Secretary information on clinical quality measures and such other measures selected by the Secretary.

Now we’re talking! I provide quality care. I use a certified EMR. I’m connected. I just need to periodically send stuff to the Secretary and the cash comes rolling in. (I admit that I’m a bit confused by the “other measures” thing, but I doubt that it’s that important.)

To the uneducated public, the goals and requirements sure seem to be a dose of good old-fashioned common sense. For instance, everyone wants their doctor to “provide summaries for patients for each office visit”. And who couldn’t be moved by this:

“Meaningful use of certified EHR technology should result in health care that is patient-centered, evidence-based, prevention-oriented, efficient, and equitable.”

Sounds lofty, but try substituting a word like “nursing” for “certified EHR technology” in the above quote and you’ll quickly realize why trying to regulate the obvious becomes inane.

Therein lies the problem. Many of the requirements either set the bar too low or seem to be an obvious functionality of EMRs. These include: “maintaining an active medication and allergy list”, or having a chart with demographics and basic vital signs recorded.

Provisions for decision support and information exchange, on the other hand, are worthwhile pursuits, but may be more difficult to achieve.

The CPOE requirements will have minimal impact. Bigger hospitals will figure out how to meet the measly 10% CPOE requirements by mandating use for house staff or emergency departments.

This is my biggest concern about the proposed measures. Much like the current E/M coding nightmare, insane attempts to limit “gaming the system” only serve to create a whole cottage industry devoted to — gaming the system!

I can’t help wondering when the real incentives will occur — that is, when a free-market public, confronted with a transparent medical system, will be allowed to make choices based on “meaningful value”.

In the mean time, I’ll try to get all that I can.

To paraphrase Dudley Moore: “I’m always looking for meaningful one-night stands”.

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.