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Electronic Medical Records:
Meaningful Use & Usability
By Charles Williamson, Jr., MBA/MHA
PUBLISHED: January/February 2012
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Background
The story of Electronic Medical Records (EMRs) in healthcare over the last decade is one of lengthy
demos, webinars, “the future,” and down payments. And though EMR platforms may vary in their bells,
whistles, and targeted specialties, there seems to be
an ever-present general theme of frustration and
hope that it will get better among provider users,
management, and their staff.
Much has already been written on the EMR topics of promised efficiency and cultural challenge. Still, not enough can be said about the practical effect of these software platforms on a care delivery system. This is now a care delivery environment going through rapid transition and protocol change in an attempt to be able to prove Meaningful Use of an EMR platform. So, what does that mean actually?
The answer is that it depends on who you are talking to and in what context. The buzz phrase of Meaningful Use means very different things to the government, software developer, patient, and provider, but, whether or not Meaningful Use will translate into Usability is the story and challenge of the decade ahead.
The Government
There is a great deal of published information about why Washington (and the States) wants EMRs. Their expressed goal is good communication across care continuums. Cost reductions, improved quality of care, promotion of evidence-based medicine, and recordkeeping mobility are just a sample of the many topics touted as opportunities provided by EMRs; the proviso being that having a patient’s entire healthcare experience in an electronic format facilitates ease of communication, information exchange, eventual efficiency, producing a better outcome at lower cost, yielding a better overall healthcare delivery system…kind of like a Windows OS for healthcare. No offense Mac users.
Whether or not you agree with the government’s care coordination formula of Streamlined Communication = Efficiency = A Better Healthcare System, it is public policy and a commercial sector at this point. With roots in the U.S. Military, coordinating care goes back several decades with the Department of Veterans Affairs (VA) Hospital System. In fact, the VA’s VistA system is one of the largest enterprise level care coordinating EMR platforms in practical use to date.
To help steer the role of EMRs in care coordination and information exchange, the U.S. Department of Health and Hospitals created the U.S. Office of the National Coordinator for Health Information Technology, also known as the ONC, in 2004 via Executive Order. It was later legislatively mandated by the Health Information and Technology for Economic and Clinical Health Act in 2009 (HITECH Act). The most significant building project of the ONC is The Nationwide Health Information Network (NwHIN), a development that will essentially “tie together health information exchanges, integrated delivery networks, pharmacies, government, labs, providers, payors, and other stakeholders into a ‘network of networks’”1…kind of sounds a little 1984-ish. Physician and public health expert Farzad Mostashari serves as the National Coordinator for Health Information Technology.
To help bolster the commercial proliferation of EMRs domestically, the HITECH Act has earmarked incentive payments for eligible Medicaid and Medicare providers who prove Meaningful Use of an EMR platform. If certain thresholds are met with regard to a provider’s total patient population, those who are significant Medicaid or Medicare providers may receive up to $63,750 over six years and $44,000 over five years, respectively. In order to receive any of these incentives, eligible providers and hospitals must demonstrate Meaningful Use as defined by the 15 Core Requirements; eligible providers must meet all 15 Core Requirements and hospitals just 14.2 The second list of 10 Menu Requirements are for both providers and hospitals, who must, in addition to meeting their Core Requirements, demonstrate Meaningful Use of at least 5 of the standards with their EMR.
Core Requirements:
• Use computerized order entry for medication orders.
• Implement drug-drug, drug-allergy checks.
• Generate and transmit permissible prescriptions electronically.
• Record demographics.
• Maintain an up-to-date problem list of current and active diagnoses.
• Maintain active medication list.
• Maintain active medication allergy list.
• Record and chart changes in vital signs.
• Record smoking status for patients 13 years old or older.
• Implement one clinical decision support rule.
• Report ambulatory quality measures to CMS or the States.
• Provide patients with an electronic copy of their health information upon request.
• Provide clinical summaries to patients for each office visit.
• Capability to exchange key clinical information electronically among providers and patient authorized entities.
• Protect electronic health information (privacy & security).
Menu Requirements:
• Implement drug-formulary checks.
• Incorporate clinical lab-test results into certified EHR as structured data.
• Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.
• Send reminders to patients per patient preference for preventive/follow-up care.
• Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies).
• Use certified EHR to identify patient-specific education resources and provide to patient if appropriate.
• Perform medication reconciliation as relevant.
• Provide summary care record for transitions in care or referrals.
• Capability to submit electronic data to immunization registries and actual submission.
• Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission.
The Software Developer
What does Meaningful Use mean for the software developer in the context of their product? Really only two things: First, it is a guideline for the development of their platform (i.e., if their EMR app doesn’t have the ability to deliver on all 25 measures, it’s at a competitive disadvantage with other products); Second, Meaningful Use Certified has now become a slogan with which software companies market their platforms to providers, clinics, hospitals, etc. Most collateral marketing material contains emphatic statements about being CCHIT (Certification Commission for Health Information Technology) Certified and the bonus money available to those delivery systems that pull the trigger and purchase that EMR platform. In fact, if the software developer has any marketing ability whatsoever, one can usually find an amortized bonus schedule of the total incentive money available from the government directly underneath the Meaningful Use Certified and CCHIT marketing statements.
This is all fine and most credible software companies are deferring a substantial amount of their fees until providers or hospitals begin receiving their bonus money from the government. The only question is, what if the platform is so intrinsically difficult and cumbersome to the provider that, after they’ve signed a purchase agreement, developed an implementation team, jumped into training/using the EMR, experienced the initial culture shock, then listed out some of the dramatic changes that must take place in order for the thing to even work at a basic level, what happens then? The answer is that while the software company may have sold a Meaningful Use Certified platform with all the capabilities of meeting all Core and Menu requirements necessary to prove Meaningful Use, it doesn’t mean the darn thing is Usable on a practical level. We’ll revisit this later.
The Patient
Let’s say you’re my doctor for a moment. How are you going to use my Electronic Medical Record in a way that’s meaningful to me, the patient? I’m interested in customer service, outcomes, privacy, and portability. Does using an EMR PC, tablet, or iPad during the exam blow my hair back? Not really. It’s cosmetic at best with the only lasting impression being that you, my doctor, are really, really, really, really tech savvy. Now, if I can get called back from the waiting room faster because I entered all my historical and demographic information into my EMR via a bank level secure web-portal, all of which gets consolidated to your iPad and throughout the course of the exam is used to visualize my progress (or lack thereof) in an attempt to demonstrate what’s going on with me, then yes, it’s awesome! If you’re a specialist and I move to Seattle next week, it’ll be meaningful if you can send the last four years of my care to my new doctor out West. Otherwise, it’s not really super meaningful to me.
The Provider
So, now let’s reverse it, let me play doctor for a moment with your EMR. Does using an EMR to assist in your care help me practice medicine in a way that’s more meaningful? It all depends really, although, if a software program that’s essentially medical chart centric drives medical decision making any more than a paper chart with the same history, maybe a little CME is in order for next year’s budget. In truth, EMRs can be used meaningfully by providers, hospitals, and their staff to make a difference and provide better outcomes. Staff stop running around trying to find missing paper charts, physicians can pull up their schedules and review patient histories ahead of time, care coordination among specialists can occur in real time via desktop sharing applications, medical prescriptions can be emailed, and on and on.
The real issue at hand for the provider/hospital is different from the other three groups. It’s not whether the EMR is Meaningful Use Certified, or whether I prove Meaningful Use by meeting all the requirements I have to, because all of that can be bought or done.
The status of things from a delivery system’s point of view is undeniably how Usable is this EMR platform in clinic, on rounds, or any other circumstance that involves documenting care to a patient? Again, it all depends really.
Some providers are more facile with laptops, iPads, Galaxies (Samsung), PlayBooks (RIM), and TouchPads (HP) and can more quickly manipulate an EMR than other providers. I’m not suggesting that usability of EMRs for providers is generationally correlated, but ask a 10-year-old today to go type a paper on a Tandy 1000 with 640K of memory and save it to a 3.5” floppy. It could be done, but it would be uncomfortable. The reverse is true for the provider today who’s a couple years away from retirement. Give them an iPad and send them into an exam room. It could be done, but it wouldn’t necessarily make that EMR more Usable for them.
Conclusion
Paper charts are about as done as Christmas lights on your neighbor’s house in late May. They’re over, finished! But, while an EMR platform can be proven to the government to be meaningful, sold by the vendor as certified, conceptualized by the patient as valuable, it doesn’t necessarily mean Usable for the provider. In fact, sold as is with no change to paper chart protocols (i.e., entering histories, demographics, meds, etc., in the exam room), EMR hurts productivity while doing very little to improve outcomes.
The future of medical charting has been legislated, developed, hyped, and sold, but using it to improve quality of care on a practical level is still a ways away. EMR Usability is an organic process that many delivery systems are working through. And by changing things like call center protocols, check-in procedures, and setting up waiting room terminals equipped with wizards for the patient to input some of their information, EMRs will become more and more Usable. Whether or not that translates into a better healthcare delivery system depends on who you are talking to and what “better” means to them.
1http://www.nhinwatch.com/performSearch.cms?channelId=2
2https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp
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