Recent hoopla over “meaningful use” (MU) is obscuring the compelling reason to adopt electronic health records (EHR). Digital transformation of medical care delivery is an economic imperative to reduce the costs of producing acceptable care—doing things right all the time, as inexpensively as possible. Digital transformation is a means to an end. The end is not “meaningful use.” Rather, it is identifying wasted resources and reallocating them to productive use.
I fear that MU rules for the first two years of HITECH will actually increase production costs for many providers seeking the incentive payments. By lowering the bar so more providers might qualify, the final rules fail to discourage simultaneous use of electronic and paper records for all data-gathering functions. In my experience, maintaining two identical systems increases costs—that is, MU-qualified providers with duplicative paper and digital information systems will incur higher overall costs than providers that continue to use only paper records.
I have seen this waste first-hand on three recent family experiences with a highly rated health system. Several paper forms were filled in by hand (by the patient, nurses, and physicians), and then the information on the forms was typed into the EHR before care could proceed to the next step. Labor costs were doubled, and data transcription mistakes could easily have occurred as data were keyboarded into the computer. Ironically, I believe that this duplicative and error-prone process could conceivably qualify for “meaningful use” payments, even though it certainly raises costs and potentially lowers quality.
I started working in health care 40 years ago as a medical records clerk. I have extensive experience with paper records, especially during my academic career as a researcher. I have subsequently devoted most of the past 20 years to promoting efficiency and effectiveness through digital transformation. Nevertheless, I have come to the conclusion that paper records should not be completely eliminated. Some data, such as a history and physical or background information provided by the patient, can be recorded more efficiently on a paper form. An intelligent scanner can then transfer the information to an EHR. On the other hand, many data entries (e.g., test results, medication orders, caregivers’ notes not made in the patient’s presence) should never exist on paper.
Today’s real challenge is to design and build integrated, intelligent record systems where data originate in the most cost-effective form but quickly migrate into interoperative electronic files. So far, I haven’t seen how the MU rules necessarily move us in this direction. Please educate me with your comments if you have figured it out; I need to know what I am missing in HITECH. Above all, I solicit your thoughts on optimal relationships between paper and electronic data collection.
Tuesday, August 24, 2010 | Posted by Jeffrey C. (Jeff) Bauer at 12:47 PM |
Is Meaningful Use Always a Step Forward?
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4 comments:
Dr Bauer:
Is the use of paper for the functions you suggest productive in a holistic system view? If a physician were to hand write patient history and physical and like information, how does this then get into the record? We would need a device to scan and convert handwriting (the device exists, but now requires investment in the device and ongoing maintenance, ultimate replacement, support for the device), we need space for the device (space is usually at a premium and has a per square foot rental cost or value), we need a workflow to take the paper from the physician and scan it (necessitating some personnel time), we then need the physician to review the conversion of his handwriting to text in the EHR (a task which would then pile up for later in the day/week/month). Other costs might include needing to maintain stocks of paper forms (printing, acquisition, stocking, storage - and maintaining a print shop), interface costs to interface the scanning/recognition devices to the EHR, and the potential other investments that would not be made using the monies spent on managing your proposed paper process.
We would also have delays in the information being made available to other users of the EHR: the time it takes to have the paper scanned and then the delay until the note is final and able to be relied upon once the physician author of the handwritten note signs off on the conversion of the paper.
Is this more efficient -- not clear. But it does detract from achieving a single location for a contemporaneous record.
What might be missed by the use of a dual system -- paper cannot flag the non-completion of required fields. The meaningful use regulations (MU) require reporting of certain information (for example: smoking cessation, vital signs, medication allergy list). While we can debate the value of some of the data elements required by MU, the fact is that if the physician fails to put them down on a paper form, by the time the paper form is scanned/recognized, the patient is gone and the costs of finding the patient to garner the required information, if this is even possible, is non-trivial in terms of monetary costs and personnel time.
Technology is not the solution to every problem, but if we believe there is clinical value in using EHRs that results in improvements in quality of care, safety, and efficiency/effectiveness of healthcare operations, then we need to address the underlying reasons why paper forms appear preferable to using the EHR for certain types of data.
One reason is more generational. Older physicians are generally accustom to using paper forms and are less adept at using a computer while having a dialog with the patient -- as is characteristic of the example you cite (history and physical). Younger physicians have less of an issue with this -- and younger patients would be less likely to have an issue with the computer being a part of the dialog.
Another reason is that until recently using a computer while engaged in a discussion with the patient interposed a barrier to the face-to-face dialog. This is less true with the development if tablet computers (the best example being the iPad).
One reason that some prefer the paper chart is that the software utilized is also a barrier and requires significant work. Here we hit a conundrum, leaving aside 'clunky' software (which is crying out for redesign): we want structured data to feed the care process. This values unambiguous data over the nuanced data that is typical of a free-form paper note.
There is an entire essay here on the irrational belief that structured data is unambiguous -- which I leave to you. Suffice it to say, by way of an example, that if asked to rate the color of a wall painted "cantaloupe" by checking a box some would check the yellow box, others the orange -- it is neither, but the conversion of analog data into a limited number of preselected choices often results in the reduction of information captured/transmitted.
MU is an imperfect prod to drive us toward what the government has determined is good for us. There are a number of caregivers for whom the solution is not to go to EHRs because the bribes (ahem, incentive payments) are inconsequential to the true costs of moving from a system that works for the provider to something that may not.
The biggest failing of MU is that characteristic of much of regulation: we require that which we can measure -- did you enter this data, did you report that data? What truly needs to occur is that significant workflow change needs to occur to gain any value from the EHR for either the provider or the patient. This is not part of MU -- and this may be good as there is no single right practice workflow that is uniformly good for all.
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