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When Does Use Become "Meaningful?"

April 17, 2009
by richard
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full of meaning, significance, purpose, or value; purposeful; significant: a meaningful wink; a meaningful choice. (Dictionary.com)

The nation is getting ready to spend $17 billion to encourage the adoption and use of the electronic health records (EHR). The legislation stipulates that in order to qualify for the incentive payments, hospitals and physicians must use an EHR that has been “certified” and the use must be “meaningful” - two words that are likely to cause a lot of discussion in the near future.

In an editorial last week in the New England Journal of Medicine (April 9,2009), Dr. David Blumenthal, recently named the National Coordinator for Health Information Technology, gave a clear indication of what a significant “purpose” might be.

“Congress apparently sees HIT – computers software, Internet connection, telemedicine – not as a means to an end in itself but as a means of improving the quality of healthcare, the health of populations and the efficiency of health care systems,” he said.

With this as the goal, we now have a clearer view of what “meaningful” use might include. Keeping this in mind, I’d like to suggest two things to consider as our institutions and professional societies gear up to weigh in on the definition of “meaningful.”

First, let us not set the bar too low. There is a fear that setting an aggressive target for use will scare off physicians and will lead to reduced adoption. On the other hand, let us remember that, $17 billion dollars later, the country is going to look back and ask whether the use of the EHR has lived up to the promise. A small example: For years, hospitals have been collecting and transmitting mandatory measures of quality mostly by manual chart extraction. The recent draft HIMMS position paper on meaningful use – a work in progress and open for comment – proposes a two year period of time during which using an EHR to create “scanned” documents of these measures would be acceptable. This would be an improvement over the current, absurd state of affairs in which clinicians, even those with EHRs, fill out manual data collection instruments – sometimes paper, sometimes Excel spreadsheets. Shouldn’t we expect that newly installed EHRs would be able to automate the collection and transmission of these measures, many of which have been around for six years or more?

Second, let us perhaps think more broadly about the HIT tools that could be used “meaningfully” to get us the quality care Congress and the nation are expecting. There is an entire spectrum of activities not requiring installation of a fully functioning EHR that could also provide “meaningful” use of HIT. Tools, for example, that provide evidence-based guidelines at the point of care; make it easier to find and share best practices; that help reduce healthcare-associated infections; and allow monitoring and analysis of how individual clinicians and systems are performing relative to peers. These are not electronic health “records” per se, but few would argue that their use would not improve quality in a “meaningful” way.



The CDS works best if it is integrated within the EHR. My colleagues and I often cringe at the thought of stopping in the middle of an episode of care to log-in to yet another system to search for knowledge and content. It is time consuming and an inefficient workflow style. If evidence based care, best practices, and provider assistance were built in, the EHR systems we use would be more beneficial to provider and patient on many measures.

There may be a discussion one or two levels above this one, that is: Does it pay at all to have one Doc or small group practices implement an EMR at all? Access the Avalere report and check out the numbers.



Thanks for bringing up Clinical Decision Support tools.

I agree there is an entire "envelope" outside the transaction focused CPOE / EMR applications that could clearly provide high value. Tools like the ones you mention that support the choice of therapy are an excellent example. Tools that bring evidence-based guidlines to the point of care, tools that help disseminate best practice, tools that detect HAI in real time and allow for prompt intervention, and tools that allow for monitoring and tracking one's outcomes might be others.

Thanks for your post.

I agree and find it interesting that Clinical Decision Support seldom is elaborated as "meaningful." CDS can often be deployed independent of EHRs. Perhaps the biggest example consistent with the quality and safety goals are tools that help with drug ordering. The class of information tools you outlined have also been well proven to positively impact quality and costs.