Nobody will question whether there are challenges in American healthcare.
From issues related to transparency, communication, and interoperability, the healthcare industry has steep mountains to climb to improve the way insurers, providers, and patients work together to ensure adequate healthcare services for everyone.
One of the mountains that has yet to be scaled is the collection and sharing of patient data. Electronic health records (EHRs) have been identified as one of the solutions to this interoperability problem through the efficiencies created from digitizing and standardizing patient health records.
To incentivize the adoption of EHRs, The Centers for Medicare and Medicaid Services (CMS) introduced the Meaningful Use program nearly a decade ago. Below, we will explore the intentions behind the program, survey how well it has performed, and consider ways it could be improved.
The Ideas and Intentions Behind Meaningful Use
In a webinar focused on Stage 2 of Meaningful Use, Dr. Farzad Mostashari, M.D., the former national coordinator for Health IT at the Department of Health and Human Services, explained that Meaningful Use boils down to one idea: "It's about what's right for the patient, and our goal as a country to get to better health, better healthcare, and lower costs."
The end result of EHR adoption, Dr. Mostashari stated, is that a patient's information follows them "regardless of organizational, geographic or vendor boundaries" so they can receive the best healthcare possible, wherever they are.
Meaningful Use was intended to help create the digital infrastructure necessary to support this goal.
One of the key assumptions of Meaningful Use, notes Dr. Peter Paul Yu in his article for the Journal of Oncology Practice, is that the implementation of EHRs would result in significant savings to healthcare costs that would then sustain the building of this national digital infrastructure.
This is why CMS has offered hospitals and physician groups financial incentives to comply with Meaningful Use. Those incentive dollars are meant to cover most of the costs of HIT investment for providers, notes Dr. Yu.
CMS also took a staged approach for Meaningful Use to encourage EHR adoption, promote innovation, and avoid imposing excessive burden on the healthcare providers who were tasked with implementing the new technologies:
- Stage 1: Data capture and sharing. The focus of this stage was storing health data electronically in a standardized format.
- Stage 2: Advanced clinical processes. This stage focused on using EHR software for health information exchange among providers.
- Stage 3: Improved outcomes. The goal of the last stage was to improve the quality of health information exchanged, with the intention of improving health for patients.
Even with the incentives and assistance from CMS, adoption of Meaningful Use has been inconsistent across the country.
Why There Have Been Roadblocks to Implementation
While the majority of eligible providers have adopted Meaningful Use, not all of them have hit the program's benchmarks at each stage. There have been two primary reasons for this:
1. EHR Technology Usability and User Satisfaction
Providers have struggled to meet the benchmarks of each stage because of the usability of and user satisfaction with EHR technology. Poor usability and the sheer amount of data entry involved, it turns out, has hindered physicians from using EHRs exactly as the program intended.
A 2016 analysis of end-user satisfaction with EHRs, presented at the American Medical Informatics Association Annual Symposium Proceedings, revealed that poorly designed EHR systems actually increase the mental workload of clinicians performing high-level cognitive tasks, which reduces user satisfaction, increases provider frustration, and negatively affects patient safety.
In fact, some EHRs were originally designed in the pre-Internet days, so data sharing functionality was not a priority requirement. Providers using EHRs, then, have to deal with inefficiencies that this lack of interoperability introduces.
The study showed that clinicians expect EHR systems to provide cognitive support that matches the users' high-level, task-based mental processes, not be counter-intuitive to mental or work processes.
2. Time-Consuming Data Entry
In a study published in Family Medicine in 2018 (data collection took place in 2015), researchers concluded that "primary care physicians spent more time working in the EHR than they spent in face-to-face time with patients in clinic visits."
The study showed that the average clinic visit lasted 35.8 minutes. That broke down as 19.3 minutes spent in the EHR and 16.5 minutes in actual face-to-face time with the patient.
These numbers help explain provider discontent with EHR systems, especially among older physicians. As Stephen H. Hanson, PA-C, notes in an article for Physicians Practice, many of the healthcare providers with years of experience see EHRs as an intrusion into the practice of medicine. These older physicians don't have the computer skills to cope with EHR systems and usually don't have any desire to develop them.
Many physicians, regardless of age or experience, are tired of the administrative busy work required by Meaningful Use and EHR systems because it interferes with the personal aspect of a patient visit. Because doctors spend more time looking at a screen, they spend less time engaged with patients.
Dr. Lloyd Minor, Dean of Stanford University School of Medicine, sums it up: "That most fundamental aspect of human communication, which is eye contact, now is being robbed from the medical encounter because of the electronic health record."
Combating the Emphasis on Technology Instead of Patient Care
The general industry consensus regarding EHRs and Meaningful Use is that they place too much emphasis on patient data and not enough on the patients themselves, says Bethany Nock, marketing director at medical device supplier Gebauer Company. The intention of the program -- better patient care -- has been overshadowed by the technological requirements for the program.
CMS recognized this issue and announced in late 2016 that it would be changing the program. These changes would piggyback off the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, shifting from an incentive program based on quantity to a merit-based program focused on quality.
Under the new Quality Payment Program, providers are required to participate in one of two incentive programs:
- MIPS: Merit-based Incentive Payment System
- APMs: Advanced Alternative Payment Models
In 2016, former CMS Acting Administrator Andy Slavitt said the changes would focus on achieving better outcomes through EHR systems. MACRA minimized reporting burdens on providers and signaled a shift to prioritizing value over volume. The legislation also encouraged providers to customize technology to suit their needs as opposed to changing their workflow and processes to adhere to government regulatory requirements.
The Path Forward for Meaningful Use
In early 2018, CMS Administrator Seema Verma announced an overhaul of the Meaningful Use program, renamed "Promoting Interoperability."
"We seek to ensure the healthcare system puts patients first," Verma said. "We envision a system that rewards value over volume and where patients reap the benefits through more choices and better health outcomes." The key idea of the new program is data sharing.
Verma outlined some of the key tenets of Promoting Interoperability:
- Starting in 2019, hospitals will be required to have a patient's EHR available the day they leave the hospital.
- Providers are still required to use the 2015 edition of certified EHR technology in 2019 as part of demonstrating Meaningful Use.
- Updates to EHR and related technologies include the use of application programming interfaces (APIs) for patients to collect their health information from multiple providers.
- Hospitals will have to post their standard list of prices on the internet and in a machine-readable format.
This is where companies like ours step in. PokitDok's APIs can actually introduce secure data-sharing functionality to legacy infrastructure -- even those pre-Internet EHRs. Solutions like these can move American healthcare further along the path toward interoperability.
Tags: Health Innovation