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HITECH Goal Number 1: Do No Harm

April 17, 2009
by aguerra
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The first rule of medicine is not to heal, but do no harm. Those tasked with fleshing out HITECH’s bones should operate on the same premise. By all accounts, the ability to define meaningful use as anything significant within the established framework of deadlines is impossible. The timelines are too short, and the law provides little access to capital for the implementation of electronic systems. Moreover, most hospitals don’t have the project management, workflow redesign, and (even) IT expertise in-house to implement and facilitate adoption of such sophisticated applications as CPOE and physician documentation.

Consider these items regarding the current state of HIT adoption:

April 16 — The Leapfrog Group says only 7 percent of hospitals participating in its annual survey have met its CPOE standards.

April 16 — PWC’s Health Research Institute reported that EMR implementations will be more influenced by avoiding the penalties (which start in 2014/2015), than gaining the incentives (which start in late 2010). This is actually good news, indicating prudence might prevail (though I’m not sure how many CEOs/CFOs will happily forgo the bonus payments).

April 9 — Blumenthal expresses his concern that meaningful use be defined as something achievable by the majority. “If the requirements are set too high, many physicians and hospitals may rebel — petitioning Congress to change the law or just resigning themselves to forgoing incentives and accepting penalties.” (NEJM, April 9)

April 1 — HIMSS Analytics releases its, “Draft on the Definition of Meaningful Use of Certified EHR Technology for Hospitals.” In it, the organization states that, “many in this industry would agree that the interoperability of health information is currently very limited,” then goes on to suggest a staged approach to going electronic. However, it warns, “Annual changes by the Secretary may post challenges for hospitals and health systems, as it would require them to be in a state of constant updates and upgrades. Perhaps suggesting an interval of not less than two years between changes in measures would be more reasonable to allow healthcare organizations to effectively prepare for and execute the mandates.”

March 25 —Harvard School of Public Health releases a study which find that less than 2 percent of hospitals have a comprehensive EHR (24 functionalities in all major clinical units of a hospital), and less than 8 percent had a basic EHR in place (10 functionalities in at least one major clinical unit).

What to do?

Ego must be sacrificed to pragmatism. By this, I mean those tasked with forming the definition of meaningful use should not be ashamed of defining it in terms they would have considered so weak as to be laughable if they had been given permission to also establish the timeless for meeting it.

Setting the bar “too low” would cause little harm, as forcing these systems into place without laying the necessary groundwork (see “Homework First” by Joe Bormel, M.D.) will mean far more errors. Rather than physicians rebelling against Congress as Blumenthal fears, they will rebel against the electronic systems forced upon them.

“Here’s the order (passing over a paper). You put it in,” says the non-employed doctor to the nurse.

Errors in such an environment will abound as physicians develop workarounds like flowing water taking the least obstructed path. And, as well all know, bad data in means bad data out (only faster), and that means lives lost (see “Garbage In, Garbage Out” by Jim Feldbaum, M.D.).

Advocating a slow and steady approach to anything is against my nature. I naturally bristle at people who urge caution and revision, further examination and consensus. But this is different. This is very, very hard work, and the people ultimately responsible for making it work (the physicians) cannot be ordered to follow the rules (we’re not all Kaiser). They must be consulted, trained, financially incentivized and treated with respect, perhaps a touch of deference. Understand the physician and you win the game. As an industry, I fear we are a long way off from truly understanding how to win these brilliant people over. Until we do, it’s going to be a very rough road. As such, the bar should be based not just on where we want to go, but where we are today.

Related Posts:

HITECH Deadlines Slipping Away? (April 23)




Thanks for assembling this post, and moving attention to the gap between today's state and a thoughtful but unrealistic, composite vision.

I tried the Covey-esque Begin with the End in Mind approach in this post.  That post, titled "Better Care Through HCIT 101: Part Three, Go-Live is the Springboard to Achieving Benefits - Choosing goals that deliver benefits" more or less tried a population health model where meaningful use meant lowering healthcare costs for a very large segment of our population.  It was also an approach explored by the CBO four months ago.  It also happens to include Medical Home, which addresses some of the incentive mismatches that are driving our healthcare cost problems.

In the course of doing the research, asking leading researchers, on and off the record, "will this work?", the answer that came back was pretty consistent from many sources.  Chronic disease management does work and the payoff probably begins around years four to seven.  And, although the EMR is a necessary enabler, the EMR does not produce the result.  The benefits come through better adherence to therapies and treatments that are known to have positive results (including behavioral therapies - diet, exercise, and play.)

Would accomplishing that definition of meaningful use achieve the necessary political win in a politically meaningful timeframe to justify our investments in EMRs?



Anthony Guerra is Editor-in-Chief of Healthcare Informatics. His blog contains story lineups for...