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.
“Why is meaningful use so frustrating to doctors?” Stack asked rhetorically. “It’s because you can pass bad federal policy legislation that impacts you to some extent…but for 100 percent of your patient encounters, you must use this tool. Once you go down this path, you are never separated from this tool for every patient encounter. That’s why it’s such a pressure point and pain point for clinicians, and has frustrated physicians and nurses so much,” he said, and why downtime is simply no longer acceptable in any EHR.
Referencing a September 2014 statement from the AMA that called for a “design overhaul of electronic health records to improve usability,” Stack noted the eight “usability priorities” called for in that statement, namely that redesigned EHRs need to:
Ø Enhance physicians’ ability to provide high-quality patient care
Ø Support team-based care
Ø Promote care coordination
Ø Offer product modularity and configurability
Ø Reduce cognitive workload
Ø Promote data liquidity
Ø Facilitate digital and mobile patient engagement
Ø Expedite user input into production design and post-implementation feedback
The future, Stack said, must be towards a market of EHR solutions that are more usable, user-friendly, and reliable for physicians. He demonstrated to his audience what he meant by talking into is iPhone and asking Siri how long the drive would be from Sheraton Downtown Nashville back to Lexington, Kentucky, where he said he was about to return. Siri, in an instant, answered simply, clearly, and instantly, with the correct distance and mileage. That, he said, is the level of physician usability that the next generation of EHRs need to readily demonstrate. And he urged the healthcare IT leaders in the audience to put pressure on EHR vendors to dramatically improve the usability of every EHR solution that physicians need to interact with. Contrasting Siri’s efficiency and usability with those of the current generation of EHRs, he said, “In a world where we have smartphones and technology and are easy to use,” when it comes to EHRs, “we’ve been given things that look much more like my Atari 800 did in 1980.”
Speaking of the EHR technology that physicians are being required to use, Stack said, “I do believe it will get better. I do believe we’re going through this tunnel of despair” now, one that the U.S. healthcare system will ultimately overcome. “The problem is that we took this very immature technology and foisted it on the entire healthcare system, which is one-fifth of the economy. And the use of such immature technology, in the context of the extremely busy workdays of practicing physicians, he said, “becomes unsustainable without other efficiency and productivity benefits. I work in a fast-paced environment and make high-stakes decisions with limited information.”
In the end, Stack said of his use of EHR technology, “I love that I can look up an old EKG, I love that I can find clinical information from the past that will make a difference in my treating a patient in the ER. But when we did the 2013 survey, and we asked docs what their biggest pressure point was, over 80 percent said, EHRs. They hated their EHRs. But when we asked them, do you want to go back to paper? Over 80 percent said, no way; just make them better. I think ten years from now,” he concluded, “someone standing on this stage will be complaining about something different. The technology will be better. But I have to look to folks like you to make it better.”