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

This July, Karen DeSalvo, the director of ONC, told me that her office was looking to scale back the MU regulations. Jacob Reider, ONC’s deputy director, using a delicious euphemism, also conceded that the MU Stage 2 requirements were overly “enthusiastic.” While I appreciated the forthrightness of the ONC leaders, I wondered whether they would achieve their goal. After all, scaling back is not among the core competencies of government bureaucracies.

In the past month, both DeSalvo and Reider left ONC. DeSalvo is now the acting Assistant Secretary of Health, taking a leading role in the Ebola response (after announcing she was leaving ONC, the Department of Health and Human Services clarified that she’ll still be involved in its policy decisions, though will no longer have day-to-day management responsibility). Reider simply resigned. In the past six months, in fact, more than half of ONC’s senior personnel – its chief scientist, chief nursing officer, chief privacy officer, and director of consumer eHealth – have jumped ship.

Why? The last of the $30 billion will be spent by the end of this year. While it would appear that ONC will lose its power of the purse, it’s not that simple – the plan has been that, starting next year, rather than receiving a bonus for implementing an EHR that met MU standards, doctors and hospitals would begin seeing Medicare cuts if they didn’t meet them. But with Medicare already slashing payments through a variety of other mechanisms (value-based purchasing, no pay for errors, readmission penalties and the like), many people think that it won’t have the stomach to penalize hospitals and doctors for failing to meet the increasingly unpopular MU standards.

Unpopular is an understatement – the Meaningful Use program has clearly lost the hearts and minds of clinicians and CIOs. As of this month, only two percent of eligible physicians and about one in six hospitals have successfully attested to MU2 requirements. Even former supporters have taken to calling the program meaningless abuse. Not good.

In the face of all these challenges, ONC appears adrift, stripped of its resources as it tries to administer a failing program. It’s no surprise that its leaders are rushing the exits.

What should become of ONC and meaningful use? The key thing to remember is that MU was an accidental program – one that never would have happened had the economy not tanked in 2008. So rather than trying to salvage it by tinkering around its edges, it is time to rethink the whole shebang. In this, I agree with John Halamka, the Chief Information Officer at Beth Israel Deaconess Hospital and the chair of several HIT policy committees, who believes that ONC should “declare victory” and markedly pare back meaningful use.

Declaring victory would not be unreasonable. Against the primary goal of wiring the American healthcare system, ONC’s program worked – the number of hospitals and doctors’ offices with functioning EHRs skyrocketed from 10 percent in 2008 to approximately 70 percent today. The health IT market is far more vibrant than ever before. Even Silicon Valley – which has always given healthcare a cold shoulder – has now joined in the fun, with major health IT initiatives at Apple, Google, Salesforce, Microsoft, and in garages all over San Francisco.

Rather than continuing to push highly prescriptive standards that get in the way of innovation and consume most of the bandwidth of health IT vendors and delivery organizations, MU Stage 3 should focus on promoting interoperability, and little else. Last month, an expert panel presented ONC with a reasonable set of recommendations calling for standardized, publicly available application programming interfaces (APIs), the EHR version of standardized light sockets. This change would allow EHRs to communicate with each other and developers to write apps that could link to the large systems like those built by Epic and Cerner. Promoting this kind of interoperability would be a judicious role for a smaller, less muscle-bound ONC, and for MU Stage 3.

Ending the prescriptiveness of MU doesn’t mean abandoning the goal of using EHRs to improve healthcare. Now that the vast majority of U.S. hospitals have EHRs, the stage is set to promote the outcomes we care about through Medicare’s existing programs – without micromanaging the technology. When Medicare publicly reports adherence to evidence-based practices, hospitals with health IT systems will install decision support to meet those standards. When Medicare penalizes hospitals for excess readmissions, hospitals will create electronic links to primary care clinics and nursing homes. When Medicare ties patient satisfaction to hospital payments, healthcare system will offer their patients access to laboratory results, x-rays, and on-line scheduling, to say nothing of email and telemedicine access to clinicians. When ACOs live or die based on their efficient use of resources, they will implement computer systems that help them conserve resources. It is the outcomes we care about, and hospitals and doctors should be free to use whatever IT tools (or other non-IT strategies) to achieve those outcomes. That’s the best path forward.

By the end of this decade, I believe we will look back on the 2009-2014 era and see government intervention – particularly the $30 billion incentives and the early years of meaningful use – as having helped transform medicine, finally, into a digital industry. As our IT systems get better and our processes and culture adapt, this transformation will end up improving patient care and, eventually, saving money, notwithstanding our rocky start.

So today, even as we struggle with meaningful use, let’s praise the government for knowing when to intervene. Let’s hope that tomorrow, we can praise it for doing something far harder: knowing when to stop.