The path forward for meaningful use

More meaningful use and certification criteria are not the answer.
By John Halamka
09:18 AM
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Below is my assessment of the current meaningful use program and a proposal to better serve the needs of stakeholders. I'm likely going to violate many rules with this post. First, it's over 1500 words, which is not ideal for social media. Second, there are many who will find my conclusions politically unpopular. I'm not criticizing people, I'm just commenting on ideas. Finally, many of these topics do not have black and white answers. I hope my suggestions improve upon our current trajectory. 

Where We Are

1. I believe that the meaningful use programs have served their purpose. 

Stage 1 created a foundation of functionality for everyone. That was good. Stage 2 tried to change too much too fast and required an ecosystem of applications and infrastructure that did not exist. Clinicians struggled to engage patients and exchange data because they could send payloads but there were few who could receive them. Stage 3 makes many of the same mistakes as Stage 2, trying to do too much too soon. It requires patient accessible Application Programming Interfaces (APIs) without specifying any standards. It requires sending discharge e-prescriptions although pharmacies cannot widely support the cancel transaction that is essential to discharge medication management workflow. It requires public health transactions but CMS has no authority to require public health authorities to standardize the way they receive data.   

Clinicians cannot get through a 12 minute visit, enter the necessary Stage 3 data elements, reconcile problems/allergies/medications from multiple institutions, meet the demands of the  Stage 3 clinical quality measures, make eye contact with patients, and deliver safe medical care. There needs to be a new approach. The same thing is true about certification. I believe that early stage certification set a floor on EHR capability that was appropriate.  Certification is NOT good for the next stage of maturity, which will be driven by heterogeneous use cases and dynamic technology evolution. Certification is now at the point where it threatens usability, interoperability, and EHR quality, while at the same time diverting research and development resources of health IT developers and providers.

2. I believe that volitional information blocking does not really exist. 

There may be incompetence that feels like blocking but I've never encountered a competent organization with a business need blocking the secure exchange of information. I realize that there are folks in Congress who believe that a new crime called Information Blocking necessitates civil/monetary penalties and enforcement. I have never encountered a Chief Information Blocking Officer at a health IT developer or provider organization. The barriers are lack of enabling infrastructure, data governance, uniform policies, appropriately constrained standards, and economic incentives. Focusing on information blocking is a distraction.

3. I believe we cannot solve every societal problem through regulation. 

The layers of requirements in Meaningful Use, the HIPAA Omnibus Rule, the Affordable Care Act, ICD-10 and the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) are so complex and confusing that even government experts struggle to understand the implementation details. Each of the regulations leads to various audits. My experience is that even the auditors do not understand the regulatory intent and ask for documentation that far exceeds the capabilities of existing technology. I was recently asked to support a Meaningful Use audit because the auditor wanted proof that a clinician performed a certain task during the reporting period (a report with a time and date stamp was not enough). Maybe a video of a clinician at a keyboard with a calendar/clock on the wall in the background? 

4. I do not believe that adding numerous structured data elements and new quality measures to existing software creates disruptive innovation. We need a business imperative for change and innovation based on the needs of customers. 

I've already seen the rise of the Care Management Medical Record at our ACO, enabling care managers to examine data from all the EHRs in the community and identify gaps in care/variance from expected protocols. Patient Relationship Management applications are in development, making healthcare more like other service industries. None of this is driven by prescriptive regulation.

5. I believe that health IT developers have already committed to piloting and developing application program interfaces (APIs). 

Creating regulation before there is any industry experience as to what works makes little sense. Government can help with issues such as data governance principles, rationalizing  privacy policy,  and coordinating federal agencies but should not specify workflow or business process.