How Meaningful is Meaningful Use?

Electronic Health Records (EHRs) have been around for a very long time now.  I remember using them to chart on patients for the first time at the San Francisco VA Hospital in 1995.  I didn’t see them again until many years later when our emergency physician group switched (kicking and screaming) to an electronic version of the T-System template, and again several years later when our emergency physician group switched (kicking and screaming really, really loudly) to EPIC.  And clearly our group is in the majority.  The CMS website (http://www.cms.gov/eHealth/ListServ_Stage3Implementation.html) recently reported:

As of October 2013, 85 percent of eligible hospitals and more than six in 10 eligible professionals had received a Medicare or Medicaid EHR incentive payment. Moreover, nine in 10 eligible hospitals and eight in 10 eligible professionals had taken the initial step of registering for the Medicare or Medicaid EHR Incentive Programs as of October 2013.

Sadly, EHRs seem far behind where they should be in terms of how they advance patient care.  Most large EHRs were created as charge capture tools and as such, they excel at patient billing.  Patient care was largely an afterthought and it shows in the clinical features available in these systems, and the disruption of workflow to the providers who use these systems.

So to answer my own question, how meaningful is meaningful use?  Kinda, sorta, but not so much.

To entice providers and hospital systems to use EHRs, CMS offers financial incentives for using (which are slated, down the road, to become penalties for not using) electronic health records that meet certain “meaningful use” criteria that advance health care.  CMS wants EHRs to be more than electronic versions of paper charts.  And they need to be.

But when you consider how great EHRs could be if they utilized decision support in a more effective way, you realize that we accept a very meek definition of meaningful.  As it stands, an EHR meets criteria for meaningful use by offering very rudimentary features.  For example, and EHR meets criteria for Stage 1 Meaningful Use by listing allergies and drug-drug interactions, updating problem lists, and including one clinical decision report rule such as giving aspirin for stroke patients.  Stage 2 Meaningful Use includes clinical quality metrics such as reporting percentage of patients screened for depression, tobacco use, and obesity, and documenting that the patient has undergone or been referred for counseling.  It looks Stage 3 Meaningful Use may include patient reported data, probably through mHealth devices.  These criteria are probably better than nothing, but not necessarily by a lot.  Take some of the above examples…

Updated medication lists may or may not be accurate, updated problem lists are not necessarily vetted, and incorrect information can very easily be perpetuated from visit to visit.  The criteria are that the lists are updated, not updated correctly.  Patients may need to be enrolled in counseling programs, but not necessarily successful, and screens don’t have to be targeted (and in some cases, providers are penalized for casting too narrow a screen).   And patient reported data may be helpful, but it is just as likely to provide MORE data for providers to comb through.  MORE does not necessarily translate into better.  Without clinical analytics to vet and synthesize the data, more may actually be harmful.

What do you think?