Making Meaningful Use Meaningful
Electronic health records dramatically advance patient care. At Atrius Health, we fervently support the intent of meaningful use, a CMS program started in 2011 that provides financial incentives to organizations that use EHRs to improve patient care and penalties to those that don't. We have watched with anticipation as this program has helped move the majority of U.S. physicians to electronic patient records. However, as the program progresses, we encourage Congress and CMS to re-assess the program's sustainability. The current approach, with large-scale changes from one stage to another, is proving to be a significant challenge and may in fact hinder, rather than improve, the adoption of EHRs.
Atrius Health has extensive experience with electronic patient records -- our largest medical group, Harvard Vanguard Medical Associates, has used the Epic EHR system for more than 20 years and pioneered a home-grown EHR before that. Following suit, our other medical groups fully transitioned to Epic from 2006 to 2008.
We were the first ambulatory only group to receive HIMSS Stage 7 designation for EHR adoption and more than 80% of our physicians achieved meaningful use Stage 1. Yet as we continue to prepare for Stage 2 this year, we face unresolved challenges that may impede ease of use and efficiency. This should serve as a harbinger that many organizations nationally will not meet this hurdle.
For example, the consistent review and acknowledgement of specific sections of the patient record, such as medication list and adherence, has proved to be a significantly challenging aspect as it is asking clinicians to review medical issues outside of their area of specialty. When ophthalmologists review a medication list or problem list, they are expected to update medications or problems added by another physician. The ophthalmologist can certainly confirm whether a patient is or is not taking a medication, but if it turns out the patient is not taking a medication, should the ophthalmologist remove it from the medication list if the other physician wants the patient to take it? These clinical challenges make a simple action of clicking a "reviewed" button a complex problem.
Additionally, the complexities around transitions of care are the largest challenges we have faced thus far. We already have an extensive process for sending referral letters, but meaningful use requires that we also send a clinical summary to providers outside of our network, 10% of which should be electronic. The challenge is in the details -- specifically the timing. If the summary is sent when the physician makes the referral, it could go to the wrong provider as the patient may choose to see a different physician, potentially resulting in disclosing an extensive portion of a patient's record to a physician who may never see the patient. If we send the clinical summary when the appointment is scheduled, the correct receiver of information would improve. However, many referrals are scheduled several months in advance so sending a clinical summary when the appointment is scheduled may have less accurate information because of the lag time before the actual appointment. In addition, many clinicians have no interest in seeing all of this information, nor does the patient always want to disclose all of this information to a provider managing only a small aspect of their care.
Finally, and most importantly, Massachusetts is an "opt-in" state for our health information exchange (Mass HIWay). The difficulty of implementing that and the meaningful use requirements has created an unusual dichotomy where everyone is preparing to send transactions, but as of today, no Massachusetts organization is prepared to receive clinical summaries.
So what do we recommend?
First, make Stage 2 the final "stage" of meaningful use. Planning Stage 3 right now will only hinder progress. Instead, move forward with a long-term plan that CMS will require EHR use and reporting for payment. Establishing a successful and ongoing standard for technology and reporting on outcomes supported by that technology will go a long way toward helping us achieve the Triple Aim -- improving care quality, improving population health and reducing health care costs. In addition, current transitions in the payer market will have a much stronger influence on the sensible adoption of technology and inform where we can find value. It is imperative that we remember that technology should be an enabling tool, and it is the use of that technology that drives change, not changes in the technology itself.
Second, every three to five years, add a small number of features as a minimum base for certification and then measure outcomes -- not just process -- from clinician groups and hospitals so we can refine reporting and comparative metrics over time. The current steps between stages are too large to absorb and are harder to achieve than anyone imagined at the outset. While the intentions clearly support improved patient care and communication, we found significant difficulty in broad implementation.
Simply raising the bar on technology, rather than measuring and demonstrating how it improves patient outcomes, may in fact reduce the success of meaningful use. It is our view that it will take five years before we can fully assess the impact of this work. As with all good policy, the meaningful use program will require tweaks and changes as we learn what works and what does not. We encourage Congress and CMS to work together to improve the program to ensure that we are achieving measurable outcomes that improve patient care so that adoption of electronic health records truly is meaningful.
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