Meaningful use: Born 2009 -- died 2014?

I believe that meaningful use is now doing more harm than good
By Robert Wachter, MD
09:51 AM

The policy known as meaningful use was designed to ensure that clinicians and hospitals actually used the computers they bought with the help of government subsidies. In the last few months, though, it has become clear that the policy is failing. Moreover, the federal office that administers it is losing leaders faster than American Idol is losing viewers.

Because I believe that meaningful use is now doing more harm than good, I see these events as positive developments. To understand why, we need to review the history of federal health IT policy, including the historical accident that gave birth to meaningful use.

I date the start of the modern era of health IT to January 20, 2004 when, in his State of the Union address, President George W. Bush made it a national goal to wire the U.S. healthcare system. A few months later, he created the Office of the National Coordinator for Health Information Technology (ONC), and gave it a budget of $42 million to get the ball rolling.

The first “health IT czar,” David Brailer, focused on convening stakeholders, banging the drum for computerization, and creating standards for health IT. The seemingly arcane matter of standards turns out to be crucial, since only through a common language and protocols could computer systems have any shot at sharing data with one another (“interoperability,” in IT-speak). This is not a new issue in the world of technology: a protocol known as TCP/IP was central to the success of the Internet. And standards are why your light bulbs and electrical plugs fit into their respective sockets when you bring them home from the hardware store.

Brailer did what he could with $42 million, but – when you think about trying to change the course of the $3 trillion dollar a year U.S. healthcare system – there was only so much he could do. Within five years, however, the ONC’s budget received an injection of new resources, and not a small one: from $42 million to $30 billion. The story of how that happened is an amazing blend of happenstance and opportunism.

In 2008, when Congress passed a $700 billion stimulus package to rescue the economy, it chose to spend the money on “shovel-ready” projects – those whose plans were on the drawing board. Tucked among the highway construction and railroad repair jobs that were funded was a project of a different sort: $30 billion to help the American healthcare system go digital.

Policymakers, concerned that doctors and hospitals might buy the computers with federal money and not use them, attached a very big string to the money: a set of criteria that IT vendors and those buying IT systems needed to meet to quality for the federal bucks. These criteria became known as meaningful use.

Let’s take a deep breath and review the state of the universe, circa 2009 – particularly in light of what we know today: that meaningful use has become the most controversial, even vilified, policy initiative in the health IT world, perhaps in all of health policy (okay, maybe second to Observation Status and the SGR). In 2009, very few people would have argued that it was a good idea to create a detailed set of government regulations dictating how doctors and hospitals should build and use their electronic health records. But that is precisely what MU has done. Some slopes are, in fact, slippery.

And yet, putting myself in the place of the 2009 decision-makers, I don’t see any villains, or even any particularly egregious blunders. It’s just that things have gone off the rails, which is why we now need to change course.

Okay, back to 2009. The first question: Was it a good idea to use federal money to promote health IT? My answer is yes. In 2008 only about 10 percent of hospitals and doctors’ offices had electronic health records. As long as Congress was spreading $700 billion of federal fertilizer around to stimulate the economy, why not use some of it to rectify this market failure? I think the health IT incentives were sound policy.

Second question: Did we need a set of standards to accompany these incentives? Here, too, my answer is yes. There had been earlier initiatives, mostly by private insurers, in which doctors were given “free” computers and simply put them on their shelves. That, of course, would have been scandalous when scaled up to federal size. So meaningful use, as a policy, made sense.

The third question reflects the common complaint that the federal incentives drove the purchase of “immature IT systems” – and that we should have waited until the systems were more mature. Here, too, I’m unpersuaded. A program with a longer timeline would likely not have met the shovel-ready requirement. Moreover, the vendors had been working on their EHRs for decades (Epic was founded in 1979); a couple of years’ delay wouldn’t have gotten the systems any closer to perfection. The only way that health IT was going to get better was to implement the best systems and improve them, guided by insights born of real-life experience.

So, given these facts on the ground in 2009, I believe the policy decisions were sensible. And for a while, everything went pretty well. Meaningful use Stage 1, implemented in 2010-12, consisted of achievable standards designed to ensure that EHRs were being used effectively. But it was not so prescriptive as to stand in the way of the primary goal, namely, wiring healthcare. Adoption rates soared and MU ensured that the computers were being used.

With Meaningful use Stage 2 (2012-present), things went sour. The standards became far more aggressive, veering far more deeply into the weeds of clinical practice. MU now dictated how doctors should give out handouts to their patients (they must be prompted by the computer). It held doctors and hospitals responsible for ensuring that patients viewed and transmitted their data to third parties (most patients had no idea how to do this). It forced EHRs to meet onerous disability access requirements. All of these are noble goals, but all are bells and whistles – the kinds of changes you make after you’ve nailed the basics of getting the darned machines to work safely and efficiently. I spent a morning in June watching Christine Sinsky, a primary care doctor in Dubuque, Iowa and an expert in practice redesign, struggle to survive the regulations. While the ONC’s goals were laudable, she said, meeting the MU requirements had become “like [solving] some riddle or puzzle. Life is hard enough. Why are we making it so much harder?”

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