"Meaningful Use" for Implementing an EMR

In May of 2010, I wrote an article regarding my opinion of the validity of certain indicators insurance companies use to evaluate performance — given the fact that according to their records I write 71% generic prescriptions, and my nephrology specialty rank is eight out of 14 for writing generic medication. My conclusion at the time: "I recommend you be very careful interpreting performance numbers. Until the system is better able to capture quality, you may be doing yourself a disservice relying on data such as what I showed you."

I am not the only physician concerned with organizations publishing this kind of misleading data. Why? The data submitted to the insurance company does not capture my true prescribing because it is based on what they see. They do not have access to all of my data!

People realized that the only way to fairly evaluate health care system performance was to create an "optional" system that would enable analysis of all of the data. ("Optional" is in quotes because if physicians choose not to play, there is no way they can pay their bills.) In my opinion, this need to evaluate is what gave birth to the Electronic Medical Record (EMR) movement.

The next step, once the raw data is made "digestible," is to incentivize clinical outcomes. In other words, if everyone hospitalized for a heart attack (myocardial infarction) is started on a statin as suggested by guidelines, we will pay you more than those places who do not achieve the same result. However, everyone gets the bonus if the goal is achieved. But because this is a true bonus, the goal must be ambitious, yet achievable. In my opinion, achieving payment for goal-based performance is reasonable and a wonderful motivator for action.

Therefore, what we need is criteria for meaningful use of electronic medical records. Meaningful use is really a fancy term for using computer data in a way that proves to the government and other payers of healthcare that evidence based medicine is practiced by clinicians, and that data is acted upon through clinical decision making "rules."

The above thinking is quite brilliant. The theory is quite sound. The current problem is the expense of initiating an electronic medical record. Many physicians struggle to make ends meet. Medical practice managers are dealing with rising operating costs and have identified this as their biggest challenge of 2010 (which supports my thinking that there is a health care bubble, and it is going to burst unless we enact change). Hence, one of the reasons for the American Recovery and Reinvestment Act. The act is a way for the government to make available approximately 27 billion dollars in incentive payments for doctors (or health systems that employ physicians) who adopt electronic medical record technology over the next ten years ($44,000 through Medicare and $63,750 through Medicaid per clinician).

Some in the community opine this is "easy money" for systems. Do the math: 200 providers times $44,000 equals 8.8 million dollars. What these skeptics don't realize is that in order to qualify for the up to $44,000 in incentives, physicians must use certified electronic medical records in a meaningful way. Dr. David Blumenthal, MD, MPP, and other wrote a phenomenal perspective on the meaningful use regulation in the July 13th, 2010 edition of The New England Journal of Medicine. The challenge we physicians face, in addition to paying for the system, is meeting the requirements of meaningful use.

After reviewing the stipulations of the proposal, the "transformational opportunity to break through the barriers to progress" may not be enough. With no disrespect meant, the skeptics need to understand the concept of cash flow. When I was studying accounting, I learned a lot from the Bean Counter. Bottom line, many providers don't have available capital to purchase the "auditing equipment" that will be used to truly evaluate a provider's performance. The changes in work-flow, the lost productivity, and the added time it takes to navigate the system all contribute to decreased earning potential. I haven't even mentioned the cost of the systems, the required data storage capacity requirements, the number of people needed to train...

When you review the objectives of meaningful use in detail, you will see what I mean. There are two types of objectives: a core set and a menu set. Core is consider essential and must occur. Menu of options allows for provider choice and allows for some flexibility.

Core requirements include:

• Physicians will have to maintain an active medication list for their patients.
• Please consider reviewing The Synchronized Prescription Refill Service: A Patient Centric Model for the ideal synchronizing system that can be used to keep track of different providers prescribing medication for you.
• Physicians will have to implement one clinical decision support rule and the ability to track compliance with the rule [likely based on evidence based medicine].
• Upon request, physicians will have to provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and medication allergies).
• Please consider reviewing Getting Value from Your Medical Appointments to help you navigate the quagmire that can occur if you don't follow these helpful tips to make the most of your medical appointments.
• Smoking status must be recorded for patients over 13 years of age. The American Academy of Family Physicians has developed a tobacco cessation program called the ASK and ACT program. The program helps providers integrate tobacco cessation into electronic health records.
• The template prompts clinicians to collect information about tobacco use, secondhand smoke exposure, cessation interest and past quit attempts.
• The electronic health record should also include automatic prompts that remind clinicians to encourage quitting, advise about smoke-free environments, and connect patients and families to appropriate cessation resources and materials [including the use of medication when appropriate].
• The template should be automated to appear when patients present with complaints such as cough, upper respiratory problems, diabetes, ear infections, hypertension (think me as in nephrology!), depression, anxiety and asthma, as well as for well-patient exams.

Moreover, clinicians will have to report data on 3 core quality measures in 2011 and 2012: blood-pressure level, tobacco status, and adult weight screening and follow up.

Let it be known that these "goals" are just a starting point. Therefore, physicians should make sure their choice of EMR is based on sound principles because "pigs get fat and hogs get slaughtered." Some medblogs have suggested independent providers partner with large hospital systems to help utilize the economy of scale to negotiate a return on "the independent provider's" investment (or said another way: the government's incentive) because the initial seed money may not be enough to meet all of the meaningful use criteria -- the doctor may get stuck with a bad program without help (if the software company goes out of business or starts price gouging).

There will be some hiccups in adapting the meaningful use criteria. In fact, CPOE.org notes 9 types of unintended consequences of computerized physician order entry:

1. More/New Work for Clinicians
2. Work flow Issues
3. Never Ending System Demands
4. Problems Related to Paper Persistence
5. Changes in Communication Patterns and Practices
6. Negative Emotions
7. Generation of New Kinds of Errors
8. Unexpected and Unintended Changes in Institutional Power Structure
9. Over-dependence on Technology

That said, a paradigm shift is happening in medicine today. We need to embrace the changes that are coming and realize that meaningful use is a work in progress. With perseverance, "we will progress toward electronically connected, information-driven medical care."