Meaningful Use or Meaningless Bureaucracy?

After two weeks away from the office, I’m back in the saddle in imageRedmond.  As much as I tried to pull the plug over the Holidays it was pretty hard to avoid the Christmas Eve health (insurance)  reform antics gong on in Congress.  If that wasn’t bad enough, the Office of the National Coordinator (ONC) on December 30th released a 556-page document providing interim final rules on meaningful use and qualified electronic health records.  Reading even a summary of of the rules gave me a hangover greater than anything I’ve experienced on New Years Day.  Is it just me, or are we only making everything about health, healthcare and the practice of medicine in America even more complicated and confounding than it is already?

image I mean no disrespect to the politicians, industry executives, thought leaders and others who are doing this important work.  But has anybody really stepped back and asked, “What is it exactly that we are trying to improve and how can we make getting and giving healthcare less complicated,  more affordable, and more satisfying”?

I see glimmers of hope in some of the proposed rules.  For instance, as a consumer I like the idea of being able to get a copy of my medical record in a timely manner.  I applaud directives that take a more proactive, preventive approach to health.  I really, really want my medical information to be stored electronically and shared (by my permission) with anyone who needs it.  I want my doctor to be focused on providing safe and effective treatments when I’m ill and recommending things I can do to stay healthy when I’m not.  But 556 pages of rules defining meaningful use of electronic records!

imageI think I have a far better than average grasp of contemporary  information technology, electronic health record solutions, and hospital IT systems than your average Joe.  Yet even I cannot help but feel overwhelmed when reading the ONC rules.  As an average doctor in America, how many additional full-time staffers would I need to implement, let alone keep track of all this stuff.  Would I be incented by an additional forty to sixty thousand dollars to my cumulative Medicare or Medicaid reimbursements to even bother with any of this?  It might be easier to just withdraw from those programs as so many doctors have already done.  Then who will care for our seniors and the medically underserved?

I can’t answer for my medical colleagues.  I’m not in practice anymore.  But if I was still in practice, I’m pretty sure these new rules would push me over the edge.  And that’s coming from someone who actually enjoys using technology!  And while we in America mire ourselves in all these new regulations and directives, will the rest of the world continue to innovate with much simpler, more pragmatic approaches to health IT?  That has been my observation as I’ve traveled the world.  Sometimes we are our own worst enemies. 

Bill Crounse, MD    Senior Director, Worldwide Health     Microsoft

Comments (12)

  1. Arvind R. Cavale, MD, FACE, FACP says:

    I am so glad these words actually came from you. For a while now, I have been commenting precisely what you mention here at various forums, blogs, etc. We should not be surprised by this – what could we expect from a government agency? It is my firm belief that the ultimate objective of all these programs is to eliminate all small practices in America and coalesce care into large "Walmarts of health care". Perhaps you could lend your voice here…

  2. Laura Fochtmann, M.D. says:

    I am still in practice and am also quite technologically sophisticated.  I am also a huge believer in the ability of technology to be leveraged to improve and facilitate day to day tasks, particularly those requiring integration of large amounts of information, tracking and scheduling and other pieces of "data" that are hard for individuals to manage efficiently with brain and post-it notes alone.

    Our hospital electronic record does make it possible for me to look up past lab results, past discharge summaries, current medications and other facets of a patient’s care.  I can do all of those things as well as place orders from any location at work or at home.  But in other respects our EHR system is extremely cumbersome to use, requires a great deal of extra time to find needed information and actually introduces and facilitates some errors that never would have happened in the past.  Even more problematically, its poor usability disrupts my ability to think about the various facets of the patient’s clinical presentation. Information about the patient is fragmented on multiple screens and there is no way to integrate that information in a clinically useful manner.  I end up having to print out screen shots of some of the EHR data so that I can look at it at the same time as other pieces of data (e.g., comparing last week’s X-ray result to today’s).  The notes are formatted in a fashion that is legible but impossible to read, so that I end up getting less useful information that from the less legible notes of paper-chart days.

    Your comments on the meaningful use document are spot on.  Obviously a lot of talented and committed people have put much thought into the document, but (presumably unintentionally) it resembles our EHR — filled with lots of arcane documentation requirements and important but disconnected information that no one will be able to make heads or tails of. In the end, like our EHR, I fear it will actually detract from the goals of the initiative, which should be to get people started in using an EHR in a way that will enhance patient care and clinical decision-making.  These issues (and the associated software) are much too complex to be reduced to a laundry list of "meaningful use" items.

    In my opinion, the investment in personnel time, software and hardware cost, maintenance and other costs will far outweigh any offsets from the adoption incentives or benefits of EHR use, at least in the short term.  Although you note that it will be easier for physicians to simply withdraw from programs such as Medicare and Medicaid, I suspect that an even more significant trend will be increases in physician retirement or shifts into non-clinical roles.  Such shifts are occurring already due to high malpractice premiums and the endless bureaucratic demands of managed care and various regulatory agencies, but I predict that they will accelerate even further as physicians are forced into using poorly designed and poorly implemented EHRs.  

    If the initial focus were on designing meaningfully usable systems and making them available to clinicians at little or no cost, then meaningful use would quickly follow.  

  3. hlthblog says:

    Thank you, Laura (and Arvind) for your thoughtful comments.  I suspect there are tens of thousands of clinicians who will whole-heartedly agree with you.  For all kinds of reasons, the practice of medicine has become extraordinarily complex.  Properly designed technology could help ease the pain, but arbitrary rules and regulations on how it must be used will only inhibit its adoption.

    Bill Crounse, MD

  4. I felt compelled to add 2 cents here as well.  I consult in Health IT and wrote an EMR, which is now in mothballs as it was too much for me to keep up with as things evolved, but as a partner in consulting, I too had to ponder the complication with software that is arising.

    When the consultants who are there to help and aid somewhat start seeing the same issues, where are we going from here?  I agree too there was a lot of hard work that went in to bringing the ONC recommendations about, and I think back to watching the PBS documentary, "Money Driven Medicine" and listening to the interventional cardiologist  stating he just wants to practice medicine.   In other words he’s on camera showing you "a day in the life" of what I consider one of the most highly technical/clinical occupations in healthcare as they save our lives.

    I also think back to the "Common User Interface" and wonder why it never picked up more steam, as I think any physician would dearly welcome walking into any hospital and being able to know where to find and access information with standardized screens with not having to again learn a multitude of user interfaces like we have today.  

    I had one MD tell me he had to learn 5 systems to get through his residency, and kudos to him for that effort too.   Also the Wall Street Journal was kind enough to put an article out that basically told where to go to find the "meat and potatoes" in the 500 plus word document.

    I too hope this does not prove to be too over whelming for the physicians we need.   Technology is moving so rapidly with advancements in all areas of healthcare that I might also guess there will be considerations enter the picture within the 60 day commenting period that we may not be aware of today.  

  5. Slim Jim MD says:

    Few if any doctors will read the 566 pages (the summary table p103-108 is good enough for anyone that is interested). We need to get over the number of pages as it has no real meaning.

    Most physicians will rely on their certified vendor and the functionality already available in their EHR. No vendor will long stay in business if they don’t have the functionality or they don’t help their clients.

    many of the 25 criteria are laughably simple – have a problem on the problem list. Document allergies. Come on its not that hard!

  6. Milkweed says:

    I can’t help but think that these rules will simply stamp out innovation. Startups will simply be eliminated by the high bar set by the government to even step into this now highly regulated business of EHRs. But I wonder if this is a boon to big companies like microsoft…which will invariably benefit from such regulations.

  7. Dear dr. Crounse. Thank you for asking this question in such a sharp way. I believe that the steps US is making in the first round of improving information technology use in healthcare are not even enough to reduce the gap between US and the rest of the world. I was on an industry panel working on definitions of "meaningful use" and when I questioned why don’t we push harder to deliver more benefit to patients, the answer was that what we proposed is already way too much for US policy makers. If we add just a bit more to the scope – we risk being denied flat…

    This reminds me of "no child left behind" initiative: when it was discovered that too many kids are failing tests – we lowered the thresholds to meet the goals, rather than investing in our kids. Maybe there is a wide-spread misunderstanding about the goals of healthcare?

    Healers and early physicians used to be paid only while their patients remained healthy.

    If a doc read 500 pages instead of healing people, is he doing what he is supposed to?

    Eventually the life-time medical record of each of us will be recorded on an implantable chip and there will be no question who you are, what are your allergies, blood group, medications, how to transfer the information to point of care, who has access to it, etc. It will be all there, at patient’s and his doctor’s disposal, the most up-to-date gold copy of all clinical info. We could do it today if we wanted.

    I am strong believer in socialized medicine. You don’t call your insurance company to get an approval before calling fire department when your house is on fire! There is no extra layer of money-takers between you and this life-saving service. Physicians should not worry about services covered by patient’s insurance when they make treatment choices. They should concentrate on delivering the most benefit to the patient, not to the "system". The reimbursements should be based on only one thing – the clinical outcomes. Nothing else matters. You cure people faster and fuller, with less complications, so they are back contributing to the society – you get paid! Prevention should be given much more attention than today.

    To rephrase – I think we are solving the wrong problem. We are attacking a symptom, instead of looking at the root causes of systematic failure. The loyalty of care-givers should be with patients and auto-magically everything else will be solved. Over-regulating simply inflates the middle-man layer, taking resources away from "workabees" of healthcare.

    This is strictly my personal opinion! Take it as that.

    Thank you,

    Tibor Duliskovich dr.

  8. My sense is that great minds have come together to design a solution for too many constituencies. If we asked them to create something "meaningful" for physicians and their patients, we would have a much better and more "meaningful" solution. Many physicians rather than waiting, have made their own decisions to spend their money to adopt inexpensive, user friendly systems that give them more time with their current patients, meet those patients needs, allow them the time to see more patients, and give them useful information to manage the growth and wellbeing of  their practices.

    Everyone else seems to be working on the design of the "beautiful machine" in the service of the most commonly espoused goal of  "influencing physician behaviors." When did healthcare become the system of bureaucratic control of physician behaviors as opposed to the clinician and patient led continually developing system for healing?

    As one high level policy advisor, quoting an old adage, said to me, "follow the money." If the government has the money, then the government will drive the solution and as we see, the government is incapable even of defining "meaningful use" in any "meaningful" way, let alone administer it.

    No matter how many great minds and how much capital is brought to bear on this issue, the wrong leadership focus will render any collaboration dysfunctional, especially in such a vitally important arena as our healthcare.

    I love Dr. Laura Fochtmann’s comment above. I would echo, any system that is not meaningful to the doctors and the patients, by definition will never be "meaningful."

    When joining as a senior manager in one of America’s first and at the time most successful HMO’s, a senior executive said to me, "the doctors don’t understand what business we’re in." I learned very quickly that while that statement was partially true, also true was that  the executives didn’t understand what business the doctors and patients were in. A tragic flaw that complicated collaborative planning and execution and lost the company millions of dollars in failed attempts to build an electronic medical record system years before we were discussing the issue nationally.

  9. hlthblog says:

    Thanks for all the great comments.  I’m totally on board with the assertion that it should be doctors and patients who determine what is meaningful.  But in healthcare, there is a disconnect between those providing the services, those receiving the services, and those who are paying for the services.  If people could walk into a grocery store and take whatever they wanted for free, the steak and lobster would probably fly out the door.  In our US health system, everyone wants the best services, most advanced technologies, and latest drugs so long as someone else is paying the bill.  The challenge in healthcare is creating balance and properly aligned incentives in the system.  Some would say the best way to do that is to let market forces prevail.  Others say, we need a more socialized healthcare system.  Clearly, there are drawbacks to either model. But I don’t think anyone wins (except perhaps lawyers and consultants) when we add more complexity to a system that is already too complex.

    Bill Crounse, MD

  10. Well said about the disconnect between providers of care, patients, and those with the money to pay.

    The designers of the "beautiful meaningful system" in the sky beg the question. System for what? For whose benefit?

    Without this purpose being pinned to the wall, as prominently as Carville’s "It’s the economy, stupid" our information system design will only operationalize the debate, creating an incoherent mess without solving our core challenge.

    A CIO partner of mine, in converting a national healthcare company’s system to Oracle, planned to drive fundamental change in corporate business performance and operational leadership behavior through the new system. (sound like the goal of "influencing physician behavior?"

    It was a long, laborious, expensive and exhausting venture for all concerned. Why? Because system execution charged ahead fundamental agreement on corporate strategy and on how the company needed to change.  

    An information system shouldn’t drive strategic decision-making or alignment between constituencies. Like my CIO colleague, we can force the issue ahead of the consensus but like the proverbial horse behind the cart, we’re going to experience pain and risk getting run over.

  11. cmwilkerson says:

    Dr.Crounse, your verbiage is welcomed and echoed.

    Personally, dealing with the Medicare and Medicaid bureaucracy and re-reimbursement, negates and government money for me.

  12. vishal says:

    Nice post. Seem true on most accounts but I also think that today medical practitioners are looking to avail of this federal incentive by trying to comply with the definition of meaningful use but at the same time EHR providers are looking at their own set of profits.

    This misunderstanding is mostly I believe as a result of wrong interpretation of the federal guidelines. The EHR providers need to look at these guidelines from the prospective of the practitioners who deal with different specialties.

    Each specialty EHR has its own set of challenges or requirements which I believe is overlooked by in most EHR vendors in a effort to merely follows federal guidelines. This is resulting in low usability to the practitioners, thus less ROI, finally redundancy of the EHR solution in place.

    I think ROI is very important factor that should be duly considered when look achieve a 'meaning use' out of a EHR solution. Though one may get vendors providing 'meaning use' at a lower cost, their ROI / savings through the use of their EHR might be pretty low when compared to costlier initial investment. Found a pretty useful <a href="…/emr-ehr-roi-calculator">ROI tool </a> that is pretty customizable and easy to use. It also accounts for the different specialty EHR's too.

    Some of the other useful resources on this topic:

    <a href="…/regional-extension-centers-arra-rec putting EHR's to meaningful use</a>

    <a href="…/arra-stimulus-money-44k-arra-emr-stimulus-bill-arra-ehr-stimulus-incentives criteria for EHR</a>

    Also the introduction of REC’s through the <a href="…/regional-extension-centers-arra-rec act.</a> is a great way to avail of quality EHR solutions at competitive prices. The stiff competition among not only these REC’s but also among EHR vendors ( to become a preferred vendor of a given REC) will result in lot of positives to medical practioners.

    Looking the funding provided to the REC’s, the <a href="…/regional-extension-centers-arra-rec grant allocation system</a> also promises to be an unbiased way of allocating funds. It will also help in the concept of REC’s helping out each with their own unique business models. It can be one of the possible answers to the

    <a  href="…/comment-page-1’safe vendor challenge’</a> as discussed by many critics.

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