Is “Meaningful Use” Meaningful?

Now that the “meaningful use” rule has been finalized by the Office of the National Coordinator (ONC), many organizations turn their focus to a rapid deployment of electronic medical record (EMR) systems in an effort to achieve transformation of the United States healthcare system. Unfortunately, EMR adoption is just one tool used to transform health care, and not the single transformative activity so many believe it to be. Transformation of healthcare encompasses enhancing quality of care, improving patient safety, expanding access to care, and reducing the cost of care. EMRs deployed to satisfy the criteria for “meaningful use” can impact these factors, but only within a comprehensive framework that recognizes the role of incentives, clinical decision support, and healthcare information technology (HIT) in facilitating transformation.

Introduction of new technology often distracts us from our primary task. Our fascination with the technology leads us to focus on what the technology can do, rather than what we need the technology to do. This misguided use of technology also occurs when it is used for healthcare delivery. Many EMR implementations focused on the impressive features of the EMR software rather than the workflow requirements of the clinician users.

Healthcare transformation requires a comprehensive vision of care delivery that recognizes the interrelationships of the many stakeholders. Technology by itself only helps improve those interrelationships, while the underlying structure that the interrelationships are built on remains.

Therefore, the “meaningful use” criteria are meaningful in that they help ensure the use of EMRs in ways that can enhance healthcare delivery, they do not transform healthcare. The recently passed Patient Protection and Healthcare Reform Act (2010) does much to move us toward a better healthcare system, but it too does not transform healthcare. Transformation requires many factors working together in an iterative process to deliver the expected results. Some of those factors are outlined below.

Until economic incentives of all the stakeholders align, care delivery will remain inefficient and suboptimal in quality and safety. Providers are incented to provide more care, payors are incented to withhold care, and patients, detached from the direct costs of care, have been molded to always expect care. The culture of healthcare in America is based on the false belief that more care is better care.

Transformation of healthcare requires a complete disruption of our current system of healthcare delivery. Clinical roles require redefining. Workflows will change to meet the needs of these new clinical roles, allowing the HIT tools, such as EMRs, to be leveraged to improve care. “Meaningful use” criteria is a nice first step to help ensure the effective deployment of HIT tools such as EMRs. Nevertheless, it is just a very small step towards truly transforming healthcare.

Excerpts from: – Is “Meaningful Use” Meaningful? July/August, 2010

Photo Courtesy of  Don Guerwitz Photography – First Light. Bhaktapur, Nepal

PMC 2010 – 26th Year Fighting Cancer

Dear Friend,

The cancer road stretches far into the distance. More and more people engage in a a personal fight against the disease. Therefore, we all need to fight on with them.

It’s been 26 years since my dad succumbed to cancer. He was brave, never showing fear. A year after his death, in 1985, I rode my first Pan-Mass Challenge, a charity cycling event that raises funds for the Dana-Farber Cancer Institute located in Boston, MA . The August 7-8 PMC is my 26th ride and one I am looking forward to as much as any of them. The PMC is my opportunity to engage in the fight against cancer while honoring my dad. I sure wish he was here to watch.

Over these years, I rode for friends, colleagues, and people I did not know. I hoped to offer them hope and comfort through my connection to the wonderful PMC family. Perhaps the knowledge that over 6,000 riders and volunteers really cared provided them with a bit of help as they went through one more day fighting cancer. This fight will forever be personal. It has touched my family too hard to ever be forgotten.

Thank you for being part of my PMC family and supporting me now and in years past. Without you, this ride is just 193 miles long. With you, it is a crusade, that we are winning, against a disease that hurts too many of us. Please consider boldly investing in the miracles that are unfolding today. Every single dollar (100%) of your PMC donation fights cancer. We raised more than $30,000,000 last year, reaching $270 mil. overall. I think we can do better.

Times may be tough for us, but times are tougher for those who are fighting cancer. I need you, and those looking for hope need you.

See you on the road.

To make an online eGift donation click here

or

Send checks made out to Pan-Mass Challenge to me at:

Barry P. Chaiken
14 Durham Street
Boston, MA 02115

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About the Pan-Mass Challenge

The Pan-Massachusetts Challenge raises money for life-saving cancer research and treatment at Dana-Farber Cancer Institute through an annual bike-a-thon that crosses the Commonwealth of Massachusetts.

Since its founding in 1980, the PMC has successfully melded support from committed cyclists, volunteers, corporate sponsors and individual contributors. All are essential to the PMC’s goal and model: to attain maximum fundraising efficiency while increasing its annual gift. Our hope and aspiration is to provide Dana-Farber’s doctors and researchers the necessary resources to discover cures for all cancers.

Regulate HIT Tools as Medical Devices? Yes and No

The Food and Drug Administration recently announced it is reconsidering its previous decision to exclude health information technology (HIT) tools from regulation as medical devices. When last evaluated in the late 1990s, this decision made common sense. At that time HIT consisted of rudimentary clinical documentation systems, electronic reference materials, and administrative applications. As even these tools were not well integrated with each other and into clinical workflow, they represented more of a digitization of paper-based activities rather than something truly transformational.

Today, HIT functionality far outstrips what was even dreamed about 10+ years ago. In addition, applications function in an integrated manner truly providing the clinician with a clinical experience much different than that offered using paper-based clinical documentation or simple clinical decision support tools.

The role of physicians, nurses, and other healthcare professionals is changing. These providers are becoming more dependent upon the clinical content within the HIT tools, often deferring to “decisions” made by these tools. Such examples include differential diagnosis, prescribed diagnostic and therapeutic treatments, choice of drug, and drug dose calculations. Although the previous rationale for not considering such HIT tools medical devices was based upon the intermediation of the provider between the recommended clinical activity and actual actions taken on behalf of the patient, the strong reliance on these very sophisticated HIT tools today puts this premise into question.

The FDA must study in detail the quality and safety issues inherent in integrated HIT applications before rushing to regulate HIT tools as medical devices. An uninformed effort to regulate HIT tools as medical devices may cause more harm than good. Applying the same standards used for medical devices to HIT tools makes little sense as HIT is neither a standalone application nor strictly a medical device. They are integrated applications that can impact quality and safety in ways far dissimilar to standard medical devices.

Regulation of HIT tools as medical devices is currently premature. Although HIT tools do directly impact patient care and therefore surely require some level of regulation, such regulation cannot be done without the requisite understanding of how HIT works within clinical workflow. The regulations must be constructed to advance HIT use while simultaneously protecting patients.

Excerpts from: – Regulate HIT Tools as Medical Devices? Yes and No. May/June, 2010

Photo Courtesy of  Don Guerwitz Photography – Running the Rapids, Mae Hong Son, Thailand

Health IT’s Glue

In my last column “Raison d’Être” I wrote about the importance of staying focused on making healthcare IT work to achieve the four important goals noted above: patient safety, quality care, access to care, and cost savings. In March, I addressed the HIMSS membership with these words:

Healthcare information technology is the instrument that will transform healthcare, and it is we—the informaticists, clinicians, management engineers, senior IT executives, IT specialists, and the diverse talents of so many others—who will create the applications, processes and workflows that will improve quality, safety, access and cost-efficiency.

In addition to our effort to transform care delivery through deployment of innovative software, revised processes, and creative workflows, niche applications are becoming available that allow the varied health IT tools to be sewn together to allow us to effectively tap into their potential. Without these applications we could not achieve the necessary integration of systems that permits the construction of meaningful, efficient workflows. Such workflows allow clinicians to deliver quality care safely and efficiently while satisfying the work requirements of caregivers.

The future of health IT over the next five years is in the development of these “glue” applications that allow the seamless linking of large, robust system, such as EMRs or laboratory applications, so that end users can utilize these tools in a coherent, patient-centric manner.

Excerpts from: – Health IT’s Glue. March/April, 2010

Photo Courtesy of  Don Guerwitz Photography – Angkor Watt. Siem Riep, Cambodia

Making Meaningful Use Meaningful

A short three years ago, the Office of the National Coordinator for Health Information Technology (ONC) was funded at a level of less than $150 million. Today, thanks to the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH)—part of the American Recovery and Reinvestment Act (ARRA)—the ONC received a budget of over $2 billion. In addition, no less than an additional $19 billion is set aside to facilitate the adoption of electronic medical records over the next decade.

For both industry and government, budgets provide a more reliable picture of strategy than do policy statements. Therefore, there is little doubt that the current administration expects health information technology to play an important role in reducing healthcare costs while improving quality, safety, and access, a high priority of the president.

To accomplish this goal, adoption of technology is not enough. These new tools must be utilized effectively to achieve desirable and measureable results. Therefore, almost all of the incentive funding available to providers for the adoption of health information technology is tied to the “meaningful use” of that technology.

So what is “meaningful use?” Perhaps former Supreme Court Justice Potter Stewart provides some guidance. In a 1964 opinion on an obscenity case (Jacobellis v. Ohio) the late Justice Stewart described hard-core pornography as follows:

“It is hard to define, but I know it when I see it”

In spite of the work performed by many ONC committees to date, many working in healthcare believe the ONC is taking the same approach to defining “meaningful use.”

To its credit, the ONC is working to offer providers a hard and fast definition of meaningful use backed up by exactly defined, collectable measures. By statute, the secretary of health and human services has until December 31, 2009, to issue an interim rule on meaningful use. As the rule must go out for comment for a minimum period of time, a final rule is not expected until late Q1, 2010.

Source: Making Meaningful Use “Meaningful” – PSQH, November/December, 2009

Photo Courtesy of Don Guerwitz Photography – Young Pioneers, Havana, Cuba.

Is There Any Doubt It’s Broken?

What have we learned from the Massachusetts healthcare reform effort? Although costs to the state are running higher than anticipated - a problem in a recession – about 97% of MA residents enjoy some type of healthcare insurance. Considering the national rate is about 81%, this is a monumental achievement.

As for our lessons learned, the individual mandate is necessary to achieve universal coverage and the employer mandate helps get you there.

Additionally, a competitor to the insurers must be established, whether a public option or a non-profit regional option, to incent the insurers to better manage costs.  Currently, these options do not exist in Massachusetts. The state now subsidizes healthcare insurance for those who cannot afford it by paying private insurers to cover these individuals.

Realistically, the Massachusetts reform plan is just a partial framework for what is needed nationally, not the entire plan. Any federal effort must be more broadly based and far reaching, something states, due to existing rules on trade, Medicare, and Medicaid, cannot achieve on their own.

Success requires all stakeholders to sacrifice a bit of their pie or fiefdom. Right now that is not happening fast enough or in significant areas to deliver meaningful reform. For example, there is a good argument presented by physicians for tort reform, but there is little talk about linked changes in licensing that can help identify and retrain poor physicians.

The goal needs to be universal coverage. Actually, we have that already. Unfortunately, it is very inefficient and possibly the dumbest deployment of universal coverage possible. (See – Marking 33 Years of Universal Health Coverage) Although the uninsured eventually get care now, it is the rest of us through our insurance and taxes who pay for it indirectly. And for those unfortunate enough to get seriously ill, they often lose their homes and life savings. About 50% of all bankruptcies in the U.S. are related to medical bills.

How we get to universal coverage is through a holistic approach that addresses access, quality, and cost. Considering the number of powerful stakeholders – physicians, insurance companies, pharmaceutical companies, hospitals, and consumer groups - passing any meaningful legislation would be an amazing accomplishment.

Paying $7,300 per capita per year for healthcare is way too much considering the poor outcomes we get from spending all that money. Other countries pay less and receive more value. And if you want to make the argument that the U.S. healthcare system is better at this procedure or that treatment, considering we are spending at least 40% more than the other countries, we should be trouncing those other countries on all measures of quality, safety, and clinical outcomes. Sadly, we are not.

If George Steinbrenner expects the Yankees to win the World Series every year considering he spends 40% more than any other team on payroll, is it wrong for us to expect the same from our spending on healthcare? Should we not receive the best care in the world?

Anyone who thinks healthcare is not broken is not paying attention to the facts. How it gets fixed, is debatable. Whether it is broken, is not.

Photo Courtesy of Don Guerwitz Photography – Daycare Center, Havana, Cuba.