Tuesday, April 15, 2014

Simplifying (Eliminating?) Meaningful Use of EMRs



The core premise in this blog is: Federal Meaningful Use (MU) requirements are well-intended, but like a teacher who "teaches to the test", the federal MU program created a very complicated system that might pass the test of MU, but is not producing meaningful results for patients and clinicians.  As reported in MedScape, the first formal study of this kind was published in the April 2014 issue of JAMA Internal Medicine, which shows no correlation between quality of care and MU adherence.  The study validates what common sense told many of us for the last few years.

MU Stage 1 was a jump-start for EMR adoption in the industry.  That's a good thing, I suppose, although MU also created a false market for mediocre products.  It's time to put an end to the federal MU program, eliminate the costly administrative overhead of MU, remove the government subsidies that also create perverse incentives, and let "survival of the fittest" play a bigger part in the process.  Let the fruits of EMR utilization go to the organizations that commit, on their own and without government incentives, to maximizing the value of their EMR investments towards quality improvement, cost reduction, and clinical efficiency.

When I arrived at Northwestern Medicine in 2005, it was clear very early that our EMRs (Epic and Cerner) were not being used in a meaningful way; this was several years before any broad discussion of MU in the industry.  Many Northwestern physicians were still using paper charts alongside the EMR, thus creating a fragmented and dangerous medical record for patients.  

Using the log and audit files in Epic and Cerner, we created an "EMR Utilization Dashboard" for each physician that also rolled up to the organizational level.  The data was revealing.  Outside of General Internal Medicine and a few other spotty areas, the medication list was not being used.  The problem list was not being used. Order entry for medications, prescriptions and tests was not being used.  Templates for documentation efficiency were not being used.  Clinical alerts for best practices were not being used.  Many patient encounters were not being documented in the EMR, indicating the continued use of paper records. In short, these very expensive EMRs were being used only occasionally as expensive word processors and dictation systems.

With input from all physicians, Drs. David Liebovitz, Phil Roemer, Gary Martin and I decided to develop a simple document, describing the core principles of EMR utilization.  Sarah Miller, my director of clinical applications, also played a huge part in this project. We declared that it had to be constrained to a single page, normal spacing and font, and that we had to be data driven.  It was a big success.  Over the next two years, our rudimentary EMR Utilization Dashboard showed steady and significant improvement.  I showed the dashboard and the core principles to John Glaser (then at Partners) while we were both speaking at a conference in Victoria, British Columbia.  A few years later, when John went to ONC to support David Blumenthal, John took the influence of those core principles and dashboard with him.  I'm not exactly sure what role the dashboard and those principles played in seeding the federal MU program, but I suspect they  had some degree of influence.  By the way, we (Northwestern) offered to give the code and dashboard to the EMR vendors so that all clients could benefit, but the vendors declined.  We shared them instead on the Users Groups' web sites.

Below are the simple but effective "Core Principles of EMR Utilization" that we developed and that played a huge part in the progressive value of Cerner and Epic on the Northwestern campus, and laid the foundation for a relatively easy qualification of Northwestern under the federal MU program. 

Core Principles of EMR Utilization

Encounters

·         All patient appointments/visits are to be documented in the EHR as an encounter.

·         Visit encounters should by closed by the attending physician within 48 hours of the patient visit.

Medications

·         All medication prescriptions and refills must be documented in the EHR, including those ordered in a telephone encounter.

·         Medications are to be reviewed at every patient encounter, in accordance with the individual specialty’s standard of care.

·         Every effort should be made to maintain a valid and complete list of patients’ current medications in the EHR, including end dates, discontinuing medications no longer being taken, and removing duplicate medication entries.

Problem Lists

·         All chronic, persistent patient diagnoses or complaints should be documented on the Problem List in the EHR, with the exception of highly sensitive diagnoses such as those associated with mental health care.

·         Problems should be documented using the most specific term applicable to the problem, e.g. mild intermittent asthma vs. asthma.

·         The Problem list should be reviewed and updated at every patient encounter, in accordance with the individual specialty’s standard of care, and problems not currently clinically relevant should be filed to history and marked as resolved.

Allergies

·         Allergy lists must be actively maintained for validity and completeness for all patients, including marking as reviewed when no new allergies are reported. The allergy list must be reviewed during any encounter in which a medication is ordered.

Orders

·         All patient orders must be documented in the EHR.

Progress Notes

·         All patient encounters should have an accompanied progress note that appropriately documents the history, physical, and decision-making in a way that is succinct and minimizes redundant content.

·         If dictating, notes must include the patient’s name and medical record number, the date of the encounter, and the attending physician’s name to ensure timely documentation.

In Basket

·         Patient results and messages should be reviewed within 72 hours of receipt and In Basket coverage should be assigned when clinicians are unable to respond within that time frame.

In the early days of EMRs, the pioneers like Intermountain, Vanderbilt, Duke, and Partners differentiated themselves by developing their own proprietary EMRs and then using them in a meaningful way, without any financial incentive except their own to do so.  Meaningful Use Stage 1 served a valuable purpose-- it jump-started the adoption of commercially supported EMRs in an industry that needed jump-starting.  Maybe we should cancel Stage 2 and Stage 3, spend some of that money on to seed true innovation (think DARPA for healthcare), and let survival of the fittest play a role in deciding which organizations will utilize their EMRs, and subsequent data, most effectively to improve healthcare.

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