The proposed rules for Meaningful Use (MU) Stage 3 were just released by both CMS and the ONC. Many writers have commented on these rules, and this blog post is not a commentary about the rules. As always, I recommend readers go to John Halamka’s blog. Instead, I want to comment about the whole process.
Let me start by saying that I am a strong believer in the concept of the Meaningful Use program. It is well known that healthcare in the United States is tremendously expensive, yet does not provide the levels of quality of care and patient safety that should be achievable with this outlay. The thought that fostering the use of electronic medical records (EMRs) would improve both cost, as well as quality and safety issues, is probably valid —although it should be noted that all of the countries that show better outcomes at less cost have lower adoption of EMRs than is the current state of the U.S. There is some information that the implementation of EMRs has improved outcomes, and most of these improvements have come from the vastly improved safety process of computerized order entry and -e- prescribing systems.
I believe there are three issues that need to be addressed before use of technology is going to further improve healthcare in the U.S.
What are the new MU rules trying to accomplish?
The MU rules are trying to improve quality and safety, and incorporate the generally true concept that “you cannot improve what you cannot measure.” In reality, quality and safety are difficult to define, let alone to measure. As a result, most of the measurements are of proxies — processes that are believed to improve outcomes. In the modern world, the evidence supporting these processes changes faster than the rules do. As a result, EMRs are being designed to collect data that may not be relevant by the time this data capture actually is enabled.
Who is making the rules?
MU rules are being devised by teams of “experts” who are knowledgeable, dedicated, highly intelligent, and who tend to pursue agendas based on their own experience in, and with, healthcare. Unfortunately, these people do not represent typical patient, nor are they busy healthcare providers. For instance, when we surveyed patients on their feelings towards their physicians and healthcare experience, they expressed a strong desire for uninhibited communication with their clinicians and guarantees of privacy that EMRs are, in many ways, interfering with. And studies have shown clinicians are increasingly frustrated by EMRs, which have become data entry tools rather than vehicles to record and communicate the patient story.
Are the rules in touch with the current state of technology?
At the time of the initiation of the HITECH Act, speech recognition was just coming into its own, and natural language processing (NLP) for healthcare was still a nascent technology. These technologies are now mature, but are not being implemented as well as they could be. EMRs are filled with defined fields that need to be filled with specific data elements and have constantly decreasing places where actual narrative can be entered. It is time to re-think this process so that clinicians can use tools and technologies, such as speech recognition, to tell the patient story in a flowing narrative format, and let NLP assume the burden of extracting data from the narrative. Employing the clinician as a data-entry clerk makes no sense given these technologies.
I truly believe that EMRs have the potential to improve quality and safety in healthcare. I also truly believe that the current Meaningful Use process has lost its way. It is time for a “reboot” that focuses on ways to make EMRs usable both for patients and for clinicians, rather than serving as tools for data collection, transmission, and analysis.