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.
The ONC effort to define “meaningful use” grew out of a concern that EMR adoption, without some criteria to determine that it was deployed in a way that enhanced patient care, could lead to EMR installations that did not help advance the objectives of ONC to improve care. Recognizing the burden EMR adoption placed on practices, ONC wanted to ensure that practices did not take shortcuts to incentive payments. Without qualifying criteria, incentives could flow to organizations that only used EMRs to optimize billing codes or others that did not even use the EMR in patient care. Meaningful use criteria set a minimum standard for the use of EMRs so that clinical care was positively impacted.
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.
Our unfortunate experience with the overly aggressive treatment of prostate cancer using radiation or surgery, and the use of bone marrow transplants in women with end-stage breast cancer, shows how more care can lead to worse care with increased suffering, poor clinical outcomes, and wasted resources. A 2009 study in the Archives of Internal Medicine strongly suggested that our overuse of CT scans is increasing our cancer risk with an additional 27,000 cancers generated from scans done in 2007 alone. Only through incentive reform where each of the three stakeholders is focused on health will we generate better outcomes more efficiently.
When engineers build a skyscraper, they utilize the best knowledge available on setting a foundation, using steel girders, and managing a construction site. For purposes of safety and efficiency, contractors follow strict best practices to ensure the building meets minimum standards both during construction and upon completion. No engineer wants a skyscraper to fail.
Equally, no provider, whether a physician, nurse, or healthcare delivery organization, wants to deliver sub-optimal care leading to poor outcomes. Yet, unlike skyscraper engineers, providers fail to regularly follow best practices that are proven to deliver the best results. Until providers embrace best practices and adopt new best practices as they evolve, providers will invariably fail to deliver the best care possible to their patients and waste valuable resources in the process. HIT provides a relatively simple means to access these best practices. The only obstacle is our will to embrace HIT and deploy it properly within smart, effective workflows.
The scientific method is quite simple—establish a hypothesis and through careful, reproducible experimentation, determine the validity of that hypothesis. For hundreds of years the scientific method helped make our world better. In medicine, the scientific method assists us in discovering new treatments for all types of diseases. Therefore, it is surprising the degree of resistance by both professionals and the public to effectiveness research.
Effectiveness research is no different from what we already do today. Increasing the research done on evaluating medical treatments can only help us identify the best and most efficient treatments and in turn best practices. To suggest that such research is aimed at rationing care shows a lack of understanding of the essence of medical discovery. Rationing is a policy decision outside the authority of medical research. Research is a pursuit of scientific truth as best as we can discover it.
Transformation through disruption
Transformation of healthcare requires a complete disruption of our current system of healthcare delivery. Clinical roles require redefining. The work responsibilities of physicians and nurses in the future will be much different from those of today. Nurses, using HIT and clinical decision support, will perform duties formerly only delivered by physicians, while physicians will act as care managers orchestrating the care delivery of many patients at the same time.
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. New research, generated from newly constructed clinical databases sourced from EMRs and other HIT tools, will be quickly incorporated in clinical decision support tools that can deliver this new content to the caregiver at the point of 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.
- Berrington de González, A., Mahesh, M., Kim, K.-P., Bhargavan, M., Lewis, R., Mettler, F., & Land, C. (2009). Projected cancer risks from computed tomographic scans performed in the United States in 2007. Archives of Internal Medicine, 169(22), 2071-2077.