Speaking both as a practicing emergency physician and as the immediate past president of the American Medical Association (AMA), Steven J. Stack, M.D., challenged the healthcare IT leaders in his audience on Thursday to do everything possible to encourage improvements in electronic health record (EHR) technology for the sake of frustrated physicians, when he delivered the opening keynote address at the Health IT Summit in Nashville, sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under the Vendome Group, LLC corporate umbrella) at the Sheraton Downtown Nashville, in Nashville, Tenn.
Speaking both of EHR technology itself, and of the meaningful use program under the HITECH (Health Information Technology for Clinical and Economic Health) Act, Dr. Stack told the assembled audience that physicians are not anti-technology; but that the immaturity of the EHR solutions available on today’s healthcare IT market, combined with the forced-march mandates embedded in the meaningful use program, have put practicing physicians in the U.S. collectively into an tenable situation when it comes to having to accept impediments to their clinical practice and workflow.
“Let’s concede that without the HITECH Act, we never would have been where we are now in terms of the adoption of EHRs,” Stack said. “Before 2008, about 80 percent of clinicians in hospitals didn’t use EHRs in any robust way. Now, only eight years later, about that percentage of doctors do.” But, he said, the federal government seems inevitably to apply very challenging “carrot and stick” mandates to physicians in practice, and the meaningful use program under HITECH has been a good example of an instance in which such a mandate has proven deeply frustrating to doctors.
“The [HITECH] law was passed in 2009,” Stack said, “and in 2009-2010, this incredible infrastructure was created for these FACA groups—federal advisory committees. It was an entire ecosystem. People have built entire careers serving on these committees. In theory, this was supposed to be a three-stage program. In the first stage, [we would] adopt EHRs and built infrastructure. In the second stage, share data. By the third stage, we would reach ‘nirvana.’ We were going to analyze and share data, and everybody was going to be happy. There was a carrot and stick element to this, as in every federal program. And the philosophy was, I will give you a dime if you spend 90 cents, and if you don’t spend the dime, I’ll start penalizing you dimes.” And that was on top of a mandate that had already been placed on U.S. physicians in 2008, when the Medicare Improvement and Patient Protection Act (MIPPA) required them to begin prescribing electronically.
Steven J. Stack, M.D. speaking in Nashville
Looking at the entirety of what has happened in the past several years, Stack told his audience, “I have to give the meaningful use program both credit and criticism. Credit, because we would not have the 80/20,” meaning that without it, perhaps only a small minority of physicians would otherwise have adopted electronic health records by now. “The criticism is that I believe we now have a mess, because we have to find a way to get a return on this investment, and we cannot get it collectively right now.” Stack asserted that the four core requirements made foundational by the meaningful use program—adopting certified EHRs, prescribing electronically, exchanging health information, and reporting quality outcomes—have been overwhelmed by additional layers of requirements. “Everything else” beyond those four core sets of requirements, he said, “for the most part is a creation of the regulatory process, not the legislative or statutory process. So what we get with meaningful use is an incredibly complex paradigm. And I would assert that a good idea poorly executed is a bad idea. And meaningful use was poorly executed.”
Stack said, “It was a good thing to get people digitized. We can book airplane tickets and hotels and just about everything else online; we couldn’t we do anything in healthcare except on paper? So yes, we have to move forward. But then,” he said, referring to federal healthcare officials, and especially the leaders at the Office of the National Coordinator for Health IT and at its umbrella agency, the Centers for Medicare & Medicaid Services, “they went too far, because they tried to use a single policy lever to remake large swaths of policy. And the frustration is such that we [clinicians] no longer care what you want to do. And we’re not blameless, either, I realize that.”
Still, Stack said, “Poor execution and poor design equals frustration at the end-user level.” And he went on to share a detailed story about one evening in April in the emergency department of the hospital where he works as an emergency physician, in which the ED’s EHR essentially froze and made all computing in the EHR impossible. The key point about the situation, which ultimately got resolved over several long hours, he said, is that “We’ve created this incredible vulnerability in our attempt to create this” important technology. “But we’ve created this single point of vulnerability through which everything must flow—in the ER.” Whether an EHR goes down because of a power outage, an “Internet glitch,” or for any other reason, he said, the reality is that it is incredibly frustrating for practicing physicians who now rely on its 24/7, 100-percent availability and reliability.