Juergen Fritsch

The problem with meaningful use

September 18, 2012 10:38 AM EDT

On Aug 23, the Centers for Medicare and Medicaid Services (CMS) released the final rules for Stage 2 of the Meaningful Use incentive program that seeks to accelerate adoption of electronic health records (EHR) technology among healthcare providers. Despite good intentions, there are problems with both the ‘meaningful’ and the ‘usage’ aspects of that program.

The Medicare and Medicaid EHR Incentive Programs provide financial incentives to eligible hospitals and providers for the adoption and “meaningful use” of certified EHR technology to improve patient care. The agency that oversees these programs – the Office of the National Coordinator (ONC) – is faced with the difficult task of promoting widespread adoption of EHR systems (the “use” part of Meaningful Use) while at the same time making sure that these systems are used in a meaningful way, i.e. that they lead to better patient outcomes.

Why is this a difficult task? On the one hand, promoting widespread adoption means setting the bar really low, while on the other hand achieving meaningful use means defining enough rules and requirements to ensure adherence to best practices, proven processes and to enable the exchange of health information. This is reflected in a recent blog post by Dr. Farzad Mostashari, National Coordinator for Health IT at the ONC, where he said the following about the Stage 2 rules: “While any rule-making includes some compromises between the aspirational goals we want to achieve and the reality of where the market is, we continue to make progress toward the ultimate goal of nationwide health information exchanges.”

In fact, if you took the time to read through the 672 pages of Stage 2 rules, and didn’t fall asleep in doing so, you will have noticed that ONC raised the bar significantly compared to the Stage 1 rules in place today. While EHR vendors are scrambling to meet these new requirements with their existing systems, many observers are wondering whether the incentive programs are successful in achieving the stated goals.

On the surface, it appears so. As of 2011, roughly 35 percent of non-federal acute care hospitals had adopted at least a basic EHR system, a significant increase from 19 percent a year before. Since 2009, hospital adoption of at least a basic EHR system more than doubled. Looking at individual physicians, about 55 percent had adopted at least a basic EHR system in 2011, three quarters of which reported that their EHR system meets federal Meaningful Use criteria. Half of the remaining 45 percent of non-adopters indicated that they are either in the process of or planning to purchase an EHR system within the next 12 months.

The problems start surfacing when you look at how these systems are being used by physicians and other care providers. HIMSS Analytics is tracking and publishing EHR adoption rates using a model of 8 stages that reveals what specific EHR functionality is actually being used by hospitals that have adopted such technology. According to the latest available report, only 8.2 percent of acute care hospitals in the US have adopted physician clinical documentation via structured EHR templates (Stage 6 and higher).

I find that rather interesting. How can it be that such a seemingly crucial piece of EHR functionality – the documentation of clinical encounters in structured form by physicians – has not been adopted by most hospitals and ambulatory facilities that have purchased an EHR? And how are they capturing clinical documentation if not via the functionality provided by their EHRs?

The most common explanation is that clinical documentation modules in today’s EHRs suffer from two major problems: (a) they put the burden of creating structured patient data on the physicians by making them point-and-click through templates full of checkboxes, radio buttons and drop-down menus, thereby slowing them down significantly, and – more importantly – (b) they encourage the use of one-size-fits-all forms and copy-and-paste behavior that often results in cluttered, lower quality clinical documentation that fails to represent the subtleties and uniqueness of each individual patient’s story.

Not surprisingly then, at least 60 percent of all clinical documentation is still captured in unstructured narrative form – for example via dictation/transcription or a front-end speech recognition tool – and simply stored as text blobs in the EHR. While this keeps physicians productive and at the same time results in more meaningful and higher quality documentation, such unstructured documentation has not been very accessible to electronic systems in the past.

However, there are efforts underway that are already shaping the next generation clinical documentation tools – allowing physicians to stay productive by narrating patient encounters in free form while using state-of-the-art natural language understanding technologies to derive actionable, structured and codified clinical data from such clinical narratives. 

And that is going to be key to getting meaning and use out of “Meaningful Use” EHRs.