Meaningful Use Marches On

Over the past several years, medicine has become highly politicized. There is understandable concern over the magnitude of government expenditures devoted to providing healthcare. As one would expect for a political issue, substantive discussion just gets in the way. The goal is to rouse public support for your "side," whichever that might be. Politics thrives on the disconnect between words and meaning. Clarity of thought and in-depth discussion have no place.

The disconnect is created by saying one thing when you mean another. That also happens to be the definition of duplicity. Thus we have "Healthy Forests," supposedly an effort to preserve wilderness that is actually a license to clear-cut the forests and the HITECH Act that provides incentives to practitioners if they adopt decades-old, low-tech computer systems. Next comes "meaningful use."

What do patients think when they hear "meaningful use"? What would they think if they took the time to read the criteria? Would they see in those criteria, things that will benefit them directly and immediately, or would they see a bunch of legalistic double-speak likely to consume the doctor's time and attention, leaving less time for them?

When I look at the criteria, I see a bureaucracy setting the stage for a massive collection of detailed data about healthcare by electronic means. This continues a pattern that began with Medicare. Payments to hospitals were made contingent on detailed billing data. Hungry for data (meaningful or not), the government paid conforming bills and it also reimbursed the cost of implementing the computer systems used to generate the bills. The healthcare industry milked this arrangement for years and the government got the data it wanted. The government wants still more data, so it is now reimbursing (in the guise of an incentive) the cost of implementing data collection systems in the ambulatory setting. Do you see the pattern?

Make no mistake about it. Relabeling existing mundane data collection systems as Electronic Health Records (EHRs) creates the impression that they are something new and wonderful, maybe God's gift to medicine. I say this because few, if any, certified EHRs were designed from the ground up to be an electronic chart. There is not even a definition of what an electronic chart is, or should be, that is both theoretically sound and widely accepted. Furthermore, the frequent references to "structured data" in the criteria reinforce a commonly held but incorrect view that everything that is meaningful about healthcare can be reduced to fit into a discrete field defined by a data model or database.

One assumes that meaningful use implies doing something meaningful for the patient, but look at the criteria. One meaningful use criterion reads "GT 50 percent of all unique patients (≥ age 2), height, weight, and BP are recorded." Allowing that infants don't matter, if I'm using an EHR and recording weight on half my patients, what am I doing with the other half? I could understand if the criterion was 95 percent, but 50 percent! How is that meaningful?

Other core objectives of meaningful use have a similar surrealistic quality. Take for example drug-drug and drug-allergy interaction checking. I get the incentive if the function is enabled; I am not required to pay attention to it. Here is another. "GT 40 percent of all prescriptions are transmitted electronically." This is no problem if you are Kaiser with an in-house pharmacy but what about the real world? Most of my patients don't know where they are going to get their prescription filled at the time they leave the office, so to whom will I transmit it? The rest use mail-order services. I could be using the EHR to generate and print legible prescriptions for the patient to carry with them but that would not be considered meaningful. Also, the feds didn't figure out how to e-prescribe controlled substances before instituting this requirement. Duh.

This bizarre quality pervades many of the objectives. They seem perfectly reasonable, if a bit arbitrary - about as reasonable as the tax code. Being charitable, I will accept that meaningful use originated from the best of intentions, but I am reminded of Albert Camus who said:
"The evil that is in the world almost always comes of ignorance, and good intentions may do as much harm as malevolence if they lack understanding."

I envision a future in which there is less ignorance of medical information science and more progress. I hope that "meaningful use" does not stymie that progress.

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