Guest Post: The myth of ‘meaningful use’

by Robert S. Gold, MD

We, in the United States, will soon need to adopt the electronic health record (EHR). Over the past few years, of course, healthcare entities have slowly converted from the traditional handwritten medical record toward one that is totally digital. There have been a myriad of interim steps, from models which simply scan the handwritten documents into a computer system to those which begin with an electronic template complete with check boxes and drop down menus.

Some programs use dictated and transcribed elements for physician or mid-level provider entries. Some programs take the electronic record and utilize fuzzy logic to search for key words, phrases, and abnormal lab results in an attempt to assign ICD diagnosis codes.

But what is the purpose of this transition? What is the stated goal? What is the real goal to be achieved with an EHR? There are two major reasons for the development and adoption of the EHR. One we are close to achieving, the other, in my opinion, just doesn’t exist.

The desire to ensure that an electronic model of a patient’s encounters contains all of the elements needed for somebody’s perception of a “complete” record has led to the currently marketed and sold models. To know that a patient’s problem list is present, that his or her medication list and reconciliation is there, to know that the history and physical (H&P), progress notes, discharge summary, nursing notes, and all the rest of the elements that make up a traditional patient’s chart are present is a great reason to have an electronic record. It forces people to remember to make these entries. Also important is the electronic records ability to:

• Keep the patient’s inpatient and outpatient encounters available in one compendium
• Track crossover treatments provided by different specialists
• Monitor for drug interactions
• Track scheduling and follow-up visit dates

The potential to facilitate practice guidelines and order sets based on best practice is great—if the physician knows how to set them up and use them or, in specific cases, elect not to use them for the benefit of the outlier patient. So, for these reasons, I say good for the companies who have put such an important functionality together.

But, there are still problems with implementation of the so-called complete EHR. In the January 2011 edition of the Journal of AHIMA, Genna Rollins writes about the experience of Barbara Drury, president of Pricare Consulting. According to the article, Drury experienced difficulties with the EHR recording inappropriate dates at inappropriate times. She also expressed frustration with the inability of tracking patient data when someone does not have access to the electronic record and worried about those who would then develop alternative, manual, work-arounds.

Yes, there are still process issues.

In the same issue of the Journal of AHIMA, Angela Dinh writes about her inability to print portions of the medical record for physicians who are still paper-bound and do not (and maybe will not for the foreseeable future) have access to the electronic formats. In such situations, all of the defensive benefit of the electronic record is lost.

For treating physicians, the lack of assistance to help them complete meaningful documentation to drive appropriate codes assignment further hinders EHR implementation. Again, the Journal of AHIMA discusses difficulties with the patient problem list. Vendors have not been able to develop an electronic method to come up with meaningful ICD codes; therefore, coders who receive the electronic documents struggle to assign appropriate codes based on the documentation. If the record does not provide the diagnostic snapshot of what is wrong with the patient now, in real time, how can you have “meaningful use?”

If the physician treating the patient receives a pile of documentation without a method to distill that information into meaningful documentation regarding the patient’s current condition, the patient is at risk. With mounds and mounds of meaningless data from previous encounters, the physician treating the patient in an emergent situation will be unable to wallow through the data to discern what is and what is not important to that patient’s care. After repeated instances of this struggle, it is likely that eventually the physician will stop searching the electronic records, or that he or she will never read them at all.

Take a look at what vendors frequently provide for their “patient problem list.” One vendor’s list had four entries for ICD-9-CM code 401.9 variously described as:

• “Hypertension, NOS”
• “Essential hypertension”
• “Hypertension”
• “Elevated blood pressure”

All this was included in the same patient’s problem list. These conditions were mixed in with conditions the patient had been treated for, which he or she could not possibly have now based on other information in the medical record. Further complicating this electronic medical record was additional information regarding chronic conditions, history of conditions, and statuses in one conglomerate with absolutely no specificity for any of the conditions at all – and no indication of what conditions the patient has NOW.

From my experience, I have not found an electronic medical record software to help physicians stratify patient conditions in such a way as to prove beneficial to the next physician who needs that information. The software I have seen so far just doesn’t get us there.

How can you consider the electronic health record “meaningful” when, ultimately, it is of little “use” to the physicians?

I’ve tried to communicate and work with a few of the major providers of this magical EHR “panacea” and have gotten nowhere. “We are satisfied with our product,” was the response I received most frequently, although I have started discussions with at least one presumably open vendor. We’ll just have to see how that goes.

Editor's note: Gold founded DCBA, Inc., in Atlanta, a consulting firm that provides physician-to-physician programs in CDI. The goals are data accuracy, profile management, and compliance in the inpatient and outpatient arenas.