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Ethical Dimensions of Meaningful Use

March 5, 2011
by Joe Bormel, M.D.
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Projected quality, safety benefits from MU could be so substantial that non-attainment may be egregious

Healthcare touches our lives and our institutions at every level. How we live our lives, what we eat, what we do (mental and physical “exercise”), how we socialize and care for others, parents, spouse, children, friends, etc., have health and therefore healthcare dimensions.

I am currently sitting next to a hospital bed where my dad is resting. He has a naso-gastric tube, an IV, and perhaps a 50-50 chance of a trip to the OR before the weekend is over. At this point, ethics are not on my mind. I simply want an optimal health outcome for dad. But on second thought, that's all about ethics, and so is MU.

As brilliantly pointed out by doctors Stephen Miller and Alastair MacGregor, in “ Ethical Dimensions of Meaningful Use Requirements for Electronic Health Records,” Meaningful Use makes specific ethical shifts in healthcare delivery, as well as highlights ethical or moral underpinnings that are worth a moment of explicit attention. These include:

• Projected quality and safety benefits from MU could be so substantial that non-attainment may be egregious. Much more than simply the delay of a clinical and technology project without consequences, failure to meet MU staged thresholds in a timely manner might signify not only second-rate status, but confer an air of third-world competency.

• The motivation should be patients’ needs for optimal health outcomes—not a fascination with technology or incentive-seeking, or achieving a positive marketing statement, etc. How is your organization framing its MU campaign? Perhaps, “Everything we do is about helping you experience optimal health, even in sickness.”

• There will be significant pressure to make false claims about achieving MU given the breath of challenging criteria. Ironically, the pressure and desire to “do the right thing” will raise the temptation to do otherwise. That's an ethical issue. Are you at risk?

• MU will drive much greater transparency on variations in care; today, variations, such as they have seen in the Dartmouth Atlas, are comparatively crude yet objective indicators that patients’ needs aren't the primary driver of how resources are spent. How will we deal with the ensuing dialogue of “justice and equal opportunity for patients (based on need)” when the volume and quality of the data are amplified by HITECH? For more on this, see Larry Holly's Cortez Policy, here.

• The ability and MU mandate to have more “open-access” to patient care information, including the ability to “enthusiastically” share that information. Will that lead to erroneous, misinformed and harmful conclusions, with true harm, along with the true benefits of openness?

• The Miller/MacGregor article also addresses moral and ethical issues related to vendor pricing and contracting practices; clearly in contrast to practices in industries where “what the market will bear” are ethically acceptable. The whole concept of “fair and reasonable return on prior investments” has a very checkered history in healthcare. For example, when my gamma knife machine is obsolete before it's paid for (hypothetically), where I am supposed to make up the difference? How can an organization, whether budget or market-driven, plan without incorporating ROI? Should we protect ROI planning assumptions because healthcare is too important to fail?

This compelling article concludes by asking the cornerstone ethical argument: “Is meaningful use relevant to clinical practice, or is it an excessive bureaucratic requirement to spend public dollars on doctors’ (and hospitals’) computer systems?” Although I'm sure there is consensus on the former, i.e. this is all about improving clinical practice, that message is too often lost at the local and community levels.

In closing, as I look at my dad in the hospital bed and contemplate what will happen next for him, these ethical issues are far from academic. They are absolutely real. What do you think?
 

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Alastair, thanks again for the fascinating article as well as your kind words.

It's now Sunday and dad is still hospitalized, the NGT is out, and he's still NPO. So, we're not out of the woods but we've avoided the knife, so far.

I have read several US-based articles on who owns the patient's record. The politically and semantically correct answer cited is usually that the institution (or doctors office) owns the physical or electronic record, and the patient owns its content. That sounds nice but that's all.

The work of gearing up for Accountable Care contains a large measure of patient engagement. That always includes a networked-PHR when done adequately. I'm dancing away from the discussion of printed copies, and, as you know, so is MU. Since we're not there yet, patient engagement with a patient summary that the patient owns, whether paper or electronic/media is the available vehicle.

I really like the idea promoted by many that a care plan is a baton. It is handed off, including to the patient, whom, if capable, is carrying it most of the time. The informational content of the baton is the patient record. The context and dynamic part is the trust and explicit pact between patient and their providers. Larry Holly of SETMA has written most about this (link) in the HCI blogs recently.  I addressed hand-offs in general and in healthcare in BlindSpots4, here.

I give an alternative view. An institution that puts in an EHR that has most of the basics of MU, communicates with at the very least its community wide physicians, has a electronic portal for patients, has chronic disease managment tools, and a wireless provider collaboration tool (smartphone messaging)...BUT DOES NOT SPEND A PENNY ON CHASING MEANINGFUL USE DOLLARS, will be far better off in the long run. I see hundreds of organizations spending millions on people and technology to prove their certified system can meet Stage 1, 2, and 3. I see the risk of no MU dollars vs. even getting it as a wash at best. In the long run that organization will have a great system that meets accountability measures with great outcomes and satisfied stakeholders. Just a different view on chasing the carrot.

Firstly and much more important than MacGregor's ramblings is the great sadness that I read of your and your Dads personal circumstances. Our thoughts and prayers go to you and all your family and wish your Dad a speedy and a complete recovery.
 
We are at that age when we are privileged to be in a position to care and return the sacrifices our parents of the "Greatest Generation" made on our behalf. We have been living through the elderly parent support scenario for over a year resulting in positive out comes, so far, for parents but we are often in separate countries in recent years.
 
Secondly  my friend Steve Miller and I appreciate your insightful comments on our article. Although I have worked for several provider organizations as well as several vendors, I have experienced relative transparency in our vendor contracting.  That said, the moral hazard exists for many, as we described in the paper.
 
As always I enjoyed your cerebral commentary and was touched by the personal circumstances. Your comments are appropriate.
 
I would appreciate this groups thoughts on who owns the patients record? Having my clinical career in the publically funded UK NHS the philosophy there was "the government on behalf of the patient" NOT the physician. Canada has a similar approach to patients owning their information.

I hope your dad is treated well.
 

Doctor Budman,

Thanks for your comment. The creation of the meaningful use definition and associated incentive program has been a mixed blessing.

In terms of creating clarity on functionality (through certification), interoperability, improved safety, patient empowerment, and enhanced quality management capabilities, MU has been a clear net positive.

I know many organizations, led by very smart and accomplished execs who share the view you provided. Pursuing MU dollars takes them off of their strategic path and commitment to a better, stronger delivery system.

I think that a lot of the opinions brought out in the Stage 2 feedback process call that out explicitly.  Over the last two or three decades, "informatics" has seen progress but limited progress in the areas outlined above, with policy-based and market-based initiatives showing frustrating shortfalls.  The current ARRA/HITECH/MU model of knitting together a funded mandate is a distinctly new approach.  It would seem to be a worthy experiment in our pluralistic society.  The ethics of that are debatable!

Joe,
I listened in on a phone conversation between my wife (an RN and my office manager) and her mother, an 85 year old with diabetes, osteoporosis and hypertension. I was most fascinated by the fact that her mother is managing a complex regimen that includes at least 8 different drugs. She has decreased auditory acuity and as is typical of most 85 year olds, some challenges with short term memory that can lead to easy confusion.

My wife spent an exasperating 30 minutes trying to tease out the medication list that her mother was on. She will now need to call her mother's PCP to get that information, as her attempts with her mother failed.

I am truly sorry you are going through the challenges with your father at this time. Most baby boomers are experiencing some variation on this theme. Whether in the acute inpatient setting, or the chronic outpatient setting, getting accurate information is key. One can not practice the highest quality of care with incomplete and often inaccurate information. As physicians, it is our moral and ethical obligation to use whatever means are available to collect as complete a data base as possible when caring for a patient.
The problem is that if each episode is similar to my wife's efforts, we will only be able to care for a small number of patients per day!

Both of my folks have been in the hospital over the last several years and healthcare from a patient/family perspective is an eye-opener. I've had my encounters with the "system" myself (without them knowing I'm a physician) and there's is rampant crap (that's the best word I can come up with and be nice ) Just watched "The Doctor" the other day with William Hurt. Nothing much has changed since the movie was made in 1991.

The only way to live sanely within the system is to have someone else (who is assertive) there almost every second (my mother got double-dosed with coumadin within a two hours of being in a rehab hospital - no harm done).

Regarding the blog, I saved this quote the other day from somewhere "What gets measured, gets gamed."

Thanks Joe G.

My dad's small bowel obstruction* has thankfully spontaneously resolved with conservative medical management (no surgery needed).

Dr Larry Holly, in his post, The Baton (here) talks about the healthcare team, which not only includes the patient, but almost always includes the patients family. In your case, it includes co-workers and their families! Larry is a student of Peter Senge and I provided a link in my comment there that included this text that speaks to the frustrating advocacy you and I are both describing:


"[Systems Thinking involves ...] the ability to recognize when the initial direction of the organization is different from the desired outcome and follow the necessary steps to correct this mismatch."


Often, that gap is determined by the advocates, not the provider.  Increasingly, that is appropriate and necessary.

* My mentor Don Berwick reminds me that it's appropriate and necessary to state that I have my dad's explicit permission to share his story for exemplary and teaching purposes here.

Joe,
The "baton" analogy you mentioned, plus its description, is much the same as a comment I made to one of your blogs quite some time ago.

It makes perfect sense that the patient, during times when he or she is not under the active, direct care of a physician, owns the medical record. However, when hospitalized or in the physician's office, temporary ownership of the record passes from the patient.

A physician must feel ownership if the doc is to also accept responsibility to update problem lists and the general record accurately and in a timely manner. The physician must be able to control every encounter, and that requires ownership of every aspect of that encounter. In any industry, if the individual in charge of the situation is not in control, than why would that person take the risk of accepting responsibility for the processes required and the outcome? That makes no sense.

I hope your father makes a full recovery and returns to what I also hope is a happy and productive life. It certainly appears from your writing over time that you're doing all in your power to help ensure that happens.

Jack

A patient's history is owned by the patient.  Organizations are simply stewards of the record.  There is a limited exclusion in most states where the stewards are obligated to remove information that would harm the patient.

IA - Thanks for sharing your experience and the gaming quote. My dad was in the ED for dehydration. They put in an IV in the ambulance and gave him a half liter of fluid. In the ED, it was essentially turned off (keep vein open flow only) for several hours until I assertively inquired. Not a good sign when you need an advocate with a medical degree. I take this as further evidence that we need a system that doesn't demand the accountable care team to "try harder."  We need stronger processes.  They will probably be enabled by healthcare information technology, but are dependent on clinical knowledge management.

Jack - Thanks for your well wishes and your comment. Your comment about people working in other industries is spot on point. In current HR language, the term is employee engagement. In medicine, the phrase is and has been "the secret to caring for the patient is truly caring about the patient." Trust and responsibility follow naturally. Ninety-nine percent of physicians I have encountered truly and deeply care about their patients. I cannot say the other one percent doesn't. They do, however, have issues.

Tom - Thanks for your comment as well. When practicing in Pennsylvania, I had one of my critical clinical observations removed from a patient's chart to avoid economic harm that could result (loss of insurance for the patient.) With that, the substance abuse behavior causing the admission was lost.

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Joe Bormel

Healthcare IT Consutant

Joe Bormel

@jbormel

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