One can argue fairly reasonably that the CMS' Electronic Health Record (EHR) Incentive Program has accomplished one of its main goals – to increase adoption of EHR technology.
Since it was launched in 2011, more than 509,000 eligible professionals (EPs) and over 4,800 eligible hospitals (EHs) have been paid more than $28 billon in incentive dollars as of December 2014. Before congratulating ourselves, however, let's take a moment to reflect and ask the question: Has this investment increased utilization of EHR technology in a truly "meaningful" manner? More precisely, is this increase in technological adoption improving our health outcomes and providing a more efficient, safer, and cost-effective patient care experience?
We would all like to answer "yes" and feel comfortable that all of the time, resources and sometimes painful workflow discussions expended did indeed make a difference for providers and patients. But the unfortunate reality is that meeting Meaningful Use (MU) measures frequently becomes an exercise in conforming to specific technological requirements, often at the expense of clinical workflow. While the specific measure is met (and payment received), the process in which the measure was addressed is often more cumbersome for both patients and providers, sometimes resulting in a less efficient environment. That is most definitely not the goal of EHR adoption.
To understand why this happens, let's examine a common challenge facing a typical organization seeking to achieve successful MU attestation. Regardless of the specific stage or measure, comprehending that the EHR Incentive Program is, in large part, about the technology is vexing. There will be very specific, prescribed steps that must be completed in order to use the technology to meet measures.
It's also important to realize that general assumptions about EHR adoption may or may not align with your organization's technological and clinical capabilities. For example, a common assumption is that the EHR will be fully utilized by all services. While that is certainly the ultimate goal, the reality is that most hospitals are at various phases of implementation; some have active CPOE with physician documentation, while others might only have certain disciplines using the system. When a measure requires discrete data (e.g., diagnosis, interpretation, etc.) that has to be entered by a physician or other professional (e.g., speech therapy or rehabilitation assessment) who is not actively using the system, the hospital is forced to come up with an alternative approach, or workaround.
Ideally, gaining wider utilization is the obvious goal, but it is often unrealistic given tight timeframes and competing internal initiatives. The result is a workaround that meets the specific measure's requirements in an unconventional way. These creative approaches frequently require implementation of additional technology such as interfaces for data from other specialty systems and additional clinical workflows (e.g., asking staff to perform dual charting or create additional assessment documentation forms that would otherwise be completed during the normal care of a patient by other disciplines).
At a time when providers are being asked to do more, in less time, with fewer resources, while caring for a larger patient population, these "additional workarounds" create negative disruption to the clinical workflow. For example, in the in-patient setting, most organizations have developed a highly organized and efficient manner for providing their specialty of care. This has been necessitated by the need to deliver appropriate standards of care in an efficient and timely manner. These processes have been refined over the years with input from multiple disciplines and resources.
The workarounds created in order to meet a specific MU measure frequently disrupt this refined process and create additional staff work effort. An example might be the return of an ER patient for a simple suture removal. Because of how the patient might have been counted for MU purposes (for instance "the all ED patients count methodology"), additional information such as family history, smoking, vital signs, summary of care, etc., may need to be documented. These requirements thereby extend the visit beyond what would normally be required on a Fast Track pathway and result in expending more resources than would normally be necessary.
Two Recommendations
So, knowing this, what should organizations do to avoid the disruption of workarounds? I would offer two suggestions.
First, for those organizations currently implementing a MU program, instead of working to check off a requirement by meeting the "letter of the law," consider looking at the bigger picture and change your goal to instead meet the "intent of the law." A classic example is the use of a Problem List for Stage 1 MU.
While post-discharge ICD-9 coding for hospitalized patients may meet the letter of the law, the actual intent of having real-time problems available during the course of patient care is missed. As a result, those organizations who approached the Problem List solely to meet the "letter of the law" are now struggling with the expanded Stage 2 measures that frequently require documentation of a real-time problem in order to drive clinical decision support at the point of care.
In this instance, organizations should use the collective creative input from the caregivers to help solve larger issues, not just the technologic "step" required by a specific MU measure. Applying this principle will provide a more solid foundation upon which to build future MU demands and quality initiates.
My second recommendation is directed toward the authors of the EHR Incentive Program. I do not think any of them envisioned (nor intended) for organizations to approach the program by creating these workarounds.
I would suggest they consider returning to the original intent of increasing technology adoption to improve the efficiency and safety of patient care. In other words, focus on the actual outcomes versus the technological steps to achieve these outcomes. The amount of time and resources spent meeting specific technological steps might be better directed at discussing how to achieve the intended outcome metric.
One idea is to allow eligible providers (EP) and eligible hospitals (EH) to come up with their own solutions to improving outcomes without being forced to adhere to a list of specific technology "check boxes." Organizations can apply their time and effort to a technology that achieves the outcome in their environment, within the limits of their given technological capability.
Driving to Desired Outcomes
CMS' EHR Incentive Program has definitely advanced the adoption of technology by EPs and EHs, but it has come at a price. The effort spent on meeting specific technological specifications and approaches to achieve MU compliance often comes at the cost of disruption to clinical workflows. The result today sometimes creates less efficient environments, while limiting true improvement to patient care, safety and efficiency.
While the EHR Incentive Program, by definition, will always need some level of technologic specification, easing these burdens would allow healthcare organizations to use their time and efforts more wisely to drive the desired outcomes. In this environment, I would strongly suspect that the discussions on how to meet given measures would go in a very different direction if organizations were freer to apply technology based on their patient population and practices.
Following this path will restore the original intent of encouraging EPs and EHs to use their technology in a "meaningful manner" to truly make a difference in patient care.
John Hoffstatter, PA-C, MS CIS, Delivery Director, Clinical Advisory Services, CTG Health Solutions, has nearly 30 years of healthcare industry experience with a focus on clinical information systems design, build, testing and support. Hoffstatter is actively licensed as a certified physician assistant and earned a master's degree in software engineering.
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