As my practice worked through the meaningful use attestation process earlier this year, I began to believe that the government was putting us through the electronic equivalent of an aerial acrobatic maneuver that would impress Ethan Hunt of “Mission: Impossible” fame. And I wasn’t pleased.
Dr. RosevearAs my practice worked through the meaningful use attestation process earlier this year, I began to believe that the government was putting us through the electronic equivalent of an aerial acrobatic maneuver that would impress Ethan Hunt of “Mission: Impossible” fame. And I wasn’t pleased.
Every story has two sides, and I try hard in my writing to at least understand the other side of an argument, even if I don’t agree with it. Unfortunately, on this topic, I’m about to give up. Electronic health records and more specifically, the requirements of meaningful use associated with them, are downright silly and in my opinion possibly purposely designed so that small-town, single-specialty groups cannot possibly economically achieve them.
Let’s start, though, with some background. Even young docs like myself have seen handwritten notes that are simply illegible. We all know examples of duplicated services done simply because one hospital or physician could not communicate with another. We are aware that the paradigm of the paternal physician telling a patient what needs to be done has been replaced by one where patients expect input to their health care and access to their medical records. Thus, I can understand the desire to transition from a paper health care record system to something different.
But is a certified EHR the way to do that?
EHRs have been around for decades, but for a variety of reasons, the medical community, especially those of us who spend a considerable amount of time in the outpatient office setting, chose not to adopt them. With that in mind, the government set out to help transition the medical community to certified EHR technology. Their specific goals, directly quoted from the HealthIt.gov website, were:
• “improve quality, safety, efficiency, and reduce health disparities
• engage patients and family
• improve care coordination, and population and public health
• maintain privacy and security of patient health information.”
So far, so good. Continuing to quote from HealthIt.gov:
“Ultimately, it is hoped that the meaningful use compliance will result in:
• better clinical outcomes
• improved population health outcomes
• increased transparency and efficiency
• empowered individuals
• more robust research data on health systems.”
Excuse me? “Ultimately?” “Hoped?” Are they saying that there are no data that the method by which they chose to achieve their goals is actually going to work? Are they admitting that this is actually just one big unknown social experiment with nothing more than “hoped”-for results? Scary.
Regardless, realizing that the technology currently available is not free and that the transition costs associated with such a project were likely preventing many physicians from using EHRs, the government, with the help of the Health Information Technology for Economic and Clinical Health Act of 2009, offered compensation for groups who transitioned to EHRs. This was followed by the Medicare & Medicaid Services EHR Incentive Program, which offered further payments to physicians who could show that they were “meaningfully using” their EHR. Each of the three phases of meaningful use contains additional, more stringent requirements.
What about the results? Is this vast social experiment working? That depends on how you define success.
If you define success as increasing the percentage of providers who are using an EHR, then yes, this project is working. According to the Centers for Disease Control and Prevention, the percentage of office-based physicians using any EHR has increased from 48% in 2009 to 78% in 2013. Further, the percentage of office-based physicians who are using a “basic” EHR, one that meets the initial criteria of meaningful use, has increased from 11% to 40% over the same period, so at least by pure number of people involved, it is working.
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What about improving clinical outcomes? I’ll concede that it can be tough to measure the independent effect that EHRs have on health care. The best surrogate I could find is the concept of using EHRs to improve coordination of care among physicians (in modern health care-speak, this is done by creating “medical homes”). To test this theory, the Affordable Care Act (aka ObamaCare) created and funded a group called the Center for Medicare & Medicaid Innovation specifically to design and run trials on improving clinical outcomes by increasing coordination of health care. The results are decidedly mixed.
Two examples of projects run by the Innovation Center include the Comprehensive Primary Care Initiative and the FQHC Advanced Primary Care Practice Demonstration. In the first, the cost per Medicare beneficiary was cut by $168, but these savings were dwarfed by the $240 per beneficiary increase in cost to set up and run the medical home program.
A report on the second was just released and, again, the program will not save costs. (New Hampshire Public Radio has an excellent article that goes into more detail on the programs.) There are even data published in JAMA(2014; 311:815-25) suggesting that creating medical homes “...was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years.”
How about costs? EHRs are not cheap. According to Healthit.gov, the average cost per provider to set up an EHR is between $15,000 and $70,000. This is supported by an article in Health Affairs(2011; 30:481-9) that estimates it would cost $162,000 for setup and $85,000 in the first year alone to run an EHR for a five-person group. Personally, I think it’s higher. Why? Healthit.gov lists five categories of costs associated with EHRs specifically: hardware, software, implementation assistance, training, and ongoing network fees.
In my practice, there are two other areas that should be accounted for: additional staff and loss of productivity. Why additional staff? Given that so many of the systems are non-compatible and that, despite EHRs, we still need to communicate with other offices, many patients show up with hard copies of their records that need to be scanned into the system. Scanning is a full-time job in my office. And as anyone who has ever fruitlessly searched the EPIC media tab for that one vital document understands, scanning records into a system is a less-than-ideal solution.
Further, I have yet to meet a physician who is more productive with an EHR. In my short career, I have watched as two separate hospital systems converted from a homegrown EHR to a commercially available system. In both cases, the clinical volume that a single physician could see went down significantly for the simple reason that in addition to all of the other requirements of being doctor (ie, taking care of patients), we now are required to ensure that the documentation for each encounter meets the requirements of meaningful use. I don’t think it’s a stretch to say that the modern physician spends as much time per patient encounter doing data entry into a computer system as he or she does actually thinking about the patient.
Is it worth it? I don’t know. Not having to decipher illegible handwritten notes is certainly nice. Having a system that immediately looks for interactions between drugs is a plus. And I do truly love being able to see computed tomography scans from any computer. On the other hand, spending half my day clicking away at a computer rather than thinking about patients or taking 45 minutes to discharge a patient is frustrating.
So what does the future hold? The problem certainly isn’t going away. When President Obama signed the law into place that repealed the Medicare sustainable growth rate formula, that system was replaced by what’s called the merit-based incentive payment system, which proposes to alter our payments based on four metrics: quality, resource use, meaningful use of EHRs, and clinical practice improvement activities. The exact details of what metrics and how that will be scored haven’t been worked out, but I'll wager a pint it will involve more clicking on my computer screen and have nothing to do with patient care.
The big question I’m currently wrestling with regarding EHRs and meaningful use, though, is really just a simple math question. Given the costs of maintaining the IT infrastructure for an EHR, the additional staffing costs required to use them, and the decrease in productivity associated with using these systems, when the government stops financially supporting this experiment and goes instead to a system where it decreases the reimbursement for those physicians not using the system, will it make financial sense to simply revert back to paper and take the hit from the government (specifically, the decrease in reimbursement for those providers not able to attest to meaningful use)?
I understand that for larger groups who can amortize the above costs over a larger number of physicians that it might make sense, but for a small-town plumber like me, I doubt it.
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