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5/14/2014
09:06 AM
David M. Denton
David M. Denton
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How Meaningful Is Meaningful Use?

The government's Meaningful Use program mandating electronic health records is out of touch with reality. EHRs bog down process and can even worsen care.

advantages. Yet the process introduces many unexpected challenges, one being the extreme amount of time it takes to enter orders in some systems. Additionally, confusing interfaces, excessive alerts, and disruptions to established workflow can create risk and low user adoption. Also, I can't figure out why it is wrong to ask a nurse to help me order a chest x-ray or a complete blood count. Where is the risk in this practice?

Our hospital's system, despite being from a major vendor, is very basic, to the point of being embarrassing. It doesn't include clinical decision support and takes a lot of time to use, making it very hard to engage physicians. Excessive alerts are a major issue, and we have documented several errors from "alert fatigue." Simple design changes would go a long way to make the interfaces intuitive and usable.

Guaranteeing security is also a focus of MU Stage 2. Interestingly, doctors, while bearing the full liability of security, are totally at the mercy of their EHR vendors and IT staff. We all fool ourselves when we think anything on a server is safe from hackers.

Another major goal of MU Stage 2 is to allow patients to access their records through portals and give them exit summaries after an encounter. This has proven difficult. Although this seems like a just cause, patients don't seem to care about portals. Studies have shown that patients remain ambivalent about using them.

Personal experience supports this. Our hospital has spent all kinds of efforts trying to get patients to use a portal -- from nagging them on the phone to giving them free coupons for dinner. None has worked well, and so far, one month into attestation for MU Stage 2, 0.4% of patients have logged into the portal. It seems this MU measure might be based on someone's agenda rather than what people really want.

The benefit of providing patient summaries is also questionable when you look in our garbage cans (or parking lot), which are littered with the summaries handed out at the end of a visit.

MU Stage 2 requires that educational resources must be provided with EHR technology. It is not clear why an EHR needs to be used to identify patient resources. Ours does a poor job of providing useful information. There are much better resources, such as UpToDate, available outside of our EHR.

Providers can do a lot of things to be better at providing high-quality, consistent care that is well coordinated. They can do better at getting patients engaged. Meaningful use requires that EHRs be at the center of these improvements. The reality is that EHRs in their current iteration might not be the tool for these or other problems in medicine. They remain awkward and poorly integrated. There is great disparity between systems. Pushing MU is not addressing the bigger issue that these products need to be usable and integrated to match the very functional, safe, and effective workflows that they are trying to replace.

I am all for advancement, but trying to push a technology that is not mature nor the best one to solve the problems at hand is ill-conceived and foolish. Many of the current EHR systems are simply inadequate. Continuing to put energy into making these systems do tasks they can't isn't helping anyone. We are wasting time and resources trying to fit a round peg in a square hole. MU is pushing adoption of technology, but it is not improving the technology. It is simply making people use systems they wouldn't use without incentives.

Our institution is striving to meet MU Stage 2. I am not sure if we will be able to. Our push to meet the required metric for patient engagement is not going well. Perhaps we are doing it wrong, or we have a lot of apathetic patients. Additionally, getting staff to go out of their way to use a very time-consuming CPOE process is more than challenging. Using CPOE makes it harder to look back and see what the current orders are. In order to care for patients, we have to keep separate notes outside of the EHR, creating more than twice the work as doing it on paper. Consultants can't figure out what is going on without talking to the other providers in person. This adds to the challenge of providing good care. If an EHR fails to achieve its No. 1 objective -- being a well-organized repository of information that is pertinent to a patient -- it is of little value, even if it can meet MU.

EHRs need to be measured by usability and functionality, not whether they can achieve Meaningful Use metrics. Right now, we need to be focused on usability. Certifications mean nothing when a product doubles or triples the workload. Our EHR is a roadblock to providing well coordinated, evidence-based, efficient, and compassionate care. MU might have merit, but it is taking the focus off the bigger issue of usability.

We shouldn't be pushing for universal measures until they can be met -- and until we have evidence that they are truly beneficial.

Though the online exchange of medical records is central to the government's Meaningful Use program, the effort to make such transactions routine has just begun. Also in the Barriers to Health Information Exchange issue of InformationWeek Healthcare: why cloud startups favor Direct Protocol as a simpler alternative to centralized HIEs. (Free registration required.)

David M. Denton is a board-certified pediatrician and member of the American Academy of Pediatrics. He is a partner of the Pocatello Children's Clinic in Pocatello, Idaho, and is affiliated with Portneuf Medical Center where he currently serves as the medical staff ... View Full Bio

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dentdavi
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dentdavi,
User Rank: Apprentice
5/16/2014 | 3:48:53 PM
Re: EHR are a success in Europe
I agree that we can learn a lot from the success and failures of others outside of the US. It does seem like we are trying to reinvent the wheel. It also seems that we are aiming a little to high with our expectations of what the technology can do at present. Perhaps using systems that would transmit documents back and forth with know protocols should have been rolled out before trying codify everything and make data discrete. There could be benefit to the approach we are trying, but we are trying to fly and we can't even walk yet.
moarsauce123
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moarsauce123,
User Rank: Ninja
5/16/2014 | 6:56:56 AM
EHR are a success in Europe
EHR systems are in place in Europe for decades and simplified information exchange as well as insurance claims processing resulting in better care and substantial savings. So now finally the US gets it that doing everything with paper files might not be that great. But what happens? The wheel is reinvented in the US and it is square. Look across the pond and make use of the lessons learned in other countries...or is it to anti-american and socialist to look at the excellent health care systems in Europe?
Alison_Diana
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Alison_Diana,
User Rank: Author
5/14/2014 | 10:18:37 AM
Re: Too harsh of a judgement on Meaningful Use, EHR?
In speaking to doctors for other stories for InformationWeek, I've found plenty of doctors who agree that EHRs are difficult to work with and introduce more work into an already busy schedule. That's one reason some practices switched their EHRs (as discussed in EHR Swaps Coming for Many Organizations). It's one reason some providers use scribes. And it's one reason some physicians cling to their paper files, despite financial incentives and pending penalties. 
David F. Carr
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David F. Carr,
User Rank: Author
5/14/2014 | 9:35:36 AM
Too harsh of a judgement on Meaningful Use, EHR?
This is a pretty complete condemnation of electronic health records and government programs to promote their use. I hear plenty of other complaints about the specifics of the MU program, but it is it really as bad as Dr. Denton says?
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