HIT Policy Committee split over order entry

By Diana Manos
03:43 PM
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There's a snag in the proposed meaningful use Stage 2 rule, and it concerns whether or not doctors need to be good at typing. Depending on how the final requirements for Stage 2 play out, they might have to be.

The HIT Policy Committee on Wednesday was divided over a measure in the Stage 2 rule that would allow licensed professionals or scribes to enter data into a patient’s electronic health record on behalf of a doctor.

The difficulty is this: If a doctor doesn’t enter the order, he or she will not be able to see the decision support built into the EHR system that appears at that time. Decision support is supposed to help with the prevention of medical errors and is, according to federal officials, one of the reasons for the EHR incentive program in the first place.

[Commentary: Why Stage 2 MU transactions need more than SMTP.]

Most electronic health record systems only show decision support once, as the computerized physician order entry, or CPOE, is typed into a system, according to Paul Tang, MD, chief innovation and technology officer at the Palo Alto Medical Foundation and vice chair of the HIT Policy Committee. The problem is, most doctors do not type in their own orders. Nurses often enter medication orders or clerical persons type in hand written physicians’ orders, later to be “signed off on” – or approved on the computer – by the physician, often in groups of multiple orders at the end of the day.

As the proposal stands now, the physician is required to use his or her personal log-on to open the record, and he or she is the person responsible for the electronic record. The physician is also responsible for approving any information entered by someone representing him or her in a clerical sense. If doctors want to see decision support, which includes warnings about dangerous drug interactions and other health preventative and safety warnings, then the doctor must be the one to type in the information.

Some members of the committee felt the rule was never intended to make doctors into typists. And even if they are good typists, they shouldn't be required to spend their time doing it. It prescribes too much for a doctors’ workflow, and is not what the proposal framers intended.

A serious discussion arose over the CPOE subject, scribes and decision support – labeled by Tang as “the single most important objective of the entire EHR incentive program.”

Last month, the committee discussed if there were other ways a clinician could have something recorded, then take responsibility for it. A physician might want to have a licensed professional enter the CPOE and then have someone else do the clerical task of entering the progress notes. Tang urged the committee to be more specific about who can enter non-CPOE entries.

Some members of the committee were in favor of scribes entering non-CPOEs, some were against, with the major consensus among the group that the physician is ultimately responsible for what is recorded.

Tang was in favor of scribes for some things. “This does not interfere with how ever people want to enter progress notes,” Tang said, “since we don’t have that same need for a feedback mechanism" in that case.

[Commentary: Inside the MU Stage 2 NPRM: 'A difficult balance'.]

“My opinion was to let it fall where it falls, and let them decide whether their physicians were less efficient or more efficient" at typing notes, said committee member Judith Faulkner, founder and CEO of Epic. "In some cases they might be, and in other cases they might not be.” 

Gayle Harrell, a Republican state representative from Florida, said the requirement needs to fall where the liability falls. “Liability is the issue,” she said. “It’s going to be difficult to determine who’s the typist.”

“There are two separate issues,” Tang offered. “The accountability for the entire EHR and the accessibility of the information.“

Neil Calman, MD, president and CEO of the Institute for Family Health felt decision support should not be compromised. If a physician doesn’t see the decision support, what good is it? “As long as the decision support appears at the time of authorization, the person who enters the order isn’t really that important,” he said. He added that it is common practice now for physicians to sign off on CPOEs that were typed in by other people.

“I strongly disagree with that,” said David Bates, MD, chief of research for the division of general and internal medicine and primary care at Brigham and Women’s Hospital. If physicians are to see the decision support, they have to see it when they type in the order, he said. “I’ve looked at a lot of different systems, all of them deliver decision support at the time that you’re actually entering the order. I’m fine with having scribes with other things,” he added.

There was some disagreement among the committee over whether or not current certified EHR systems allowed for decision support to appear again after the order is entered. Most of the physicians in the group said it was not possible. At least one said it was. Tang said to make Calman’s idea possible, it would probably require most physicians to have their EHR systems reprogrammed. Not a feasible idea, he said.

The EHR incentive program will not move forward if a doctor has to enter everything into a system, Calman warned. This would be loading doctors with too much work.

Tang also argued, “We want people to do the work at the top of their license,” implying that for doctors, this would be practicing medicine, not typing.

The committee was pressed for time, with only Wednesday’s meeting left to smooth out an entire host of recommendations due to the Centers for Medicare & Medicaid Services by May 7. Tang called for a vote on the CPOE recommendation, with three agreeing with what is written, allowing physicians to sign off on scribes entering non-CPOE data and licensed professionals entering CPOEs, without regard to when decision support may appear in the system.

Five members were in favor of revising the recommendation to require the EHR system to show decision support to every person who enters the data, including again to the physician when signing off. And, four abstained from voting.

“Clearly, we have a split vote," Tang said. “We will have to let CMS know about that.”

CMS is collecting public comments until May 7 on the proposed Stage 2 meaningful use rules. Agency officials say the final rule will be issued some time this summer. Physicians participating in the EHR incentive program would have to comply with Stage 2 rules as early as 2013, depending on when they complete Stage 1. Physicians who do not adopt EHRs by 2015 and use them according to the new rules, will face Medicare and Medicaid reimbursement penalties.