Why meaningful use Stage 2 is so important

By John Halamka
09:30 AM

Last week my mother fell and broke her hip.

She was taken to a very good local hospital and received excellent orthopedic care.

The hospital used certified EHR technology and did their best to reconcile her medications.

They used data sources such as historical prescribing records, previous hospitalization records, and calls to a few of her physicians who are not affiliated with the hospital (her primary caregiver is in downtown Los Angeles where she worked, not near the South Bay where she lives).

Although her physicians use electronic health records, the state of California does not yet have a widely deployed healthcare information exchange (although they are trying hard). There was no way to seamlessly exchange and synthesize all her data from various sites of care.

Meaningful use Stage 1 did not mandate view/access/download/transmit data for patient/family mediated data reconciliation. Open Notes is not yet universally adopted across the country.

When she arrived at the ED with a right hip femoral neck fracture, she was in a great deal of pain and was given morphine IV.

After receiving medication, she was not able to accurately reconcile her own medications.

My father had handwritten notes, but did not have the benefit of electronically accessing her records and had limited knowledge of her current medication list. The best he could do in addition to his notes was to bring in every medication bottle he could find at home.

By the time I arrived at the hospital she had been placed on 22 medications because there was history that she had been on them at some time.

Her mental status on 22 medications was such that she was not oriented to person, place or situation.

To give family members access to her hospitalization records, she needed to sign a consent. This was challenging because  "meaningful consent" requires a full understanding of what she was signing at the same time she had an altered mental status. Once she signed, I reviewed her problem list, medication list, operative notes, history/physical, and care plans. 

My role as her son and her healthcare advocate was to assemble the care team and explain that she was on TWO medications at home, not TWENTY-TWO. How did this happen? In an effort to address various symptoms because of last year's gall bladder surgery and recurring headaches, various doctors had tried short "as needed" courses of various medications. In an effort to be complete, the hospital placed her on all of them in standing doses. Complying with this regimen caused mental status changes and further made it impossible for her to offer input as to what she should be taking. She ceased to be able to participate in physical therapy because of difficulty understanding the training.

Once each member of the care team understood the poor quality of the data they had reconciled and the lack of coordination among caregivers, they agreed with me to discontinue everything except Tylenol and an anti-hypertensive.

The next morning, my mother asked why she felt so foggy. She had no recollection of the previous two days or any of the visitors who spoke with her. She regained her involvement with the rehabilitation process and became a partner in her care planning.

Under Stage 2 of meaningful use, patient and family view/access/download/transmit to her various data sources will be required. Data exchange at transitions of care will be required. Decision support that would likely have offered best practices for medication management in the elderly would have prevented the cocktail that altered her mental status.

As I wrote earlier on Oct. 9, while reflecting on the need for optimism, the country is on a great healthcare IT trajectory. We need to walk before we can run. Clinicians throughout the country are rapidly adopting more advanced EHRs that support the workflow needed to prevent the problems my mother experienced. Stage 2 is a natural evolutionary step that requires data sharing, patient/family engagement, and decision support. These changes are occurring at a fast pace but an appropriate pace. The technology, policy, and education/training needed to safely implement them is straining all healthcare stakeholders, so I do not believe meaningful use can or should be done faster than the current timelines. 

To those who say the industry should have solved all these issues years ago, I respond that nine women cannot grow a baby in a month. It takes the focused energy of one woman for nine months.

I look forward to meaningful use Stage 2 and 3. My own family experiences illustrate why the path we're on is so appropriate and so essential. 

John D. Halamka, MD, is CIO of Beth Israel Deaconess Medical Center, chairman of the New England Healthcare Exchange Network (NEHEN), co-chair of the HIT Standards Committee, a full professor at Harvard Medical School, and a practicing emergency physician.