American College of Physicians: Internal Medicine — Doctors for Adults ®

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Monday, July 16, 2012

Meaningful use leads to meaningless records

This July will mark the 16th anniversary of the installation of our electronic medical record.

Yup. I am that weird.

Over the first 10-14 years of my run as doctor uber-nerd, I believed that widespread adoption of EHR would be one of main things to drive efficiency in health care. I told anyone I could corner about our drive to improve the quality of our care, while keeping our cash-flow out of the red. I preached the fact that it is possible for a small, privately owned practice to successfully adopt EHR while increasing revenue. I heard people say it was only possible within a large hospital system, but saw many of those installations decrease office efficiency and quality of care. I heard people say primary care doctors couldn't afford EHR, while we had not only done well with our installation, but did so with one of the more expensive products at the time. To me, it was just a matter of time before everyone finally saw that I was right.

The passage of the EHR incentive program (aka "meaningful use" criteria) was a huge validation for me: EHR was so good that the government would pay doctors to adopt it. I figured that once docs finally could implement an EHR without threatening their financial solvency, they would all become believers like me.

But something funny happened on the way to meaningful use: I changed my mind. No, I didn't stop thinking that EHR was a very powerful tool that could transform care. I didn't pine for the days of paper charts (whatever they are). I certainly didn't mind it when I got the check from the government for doing something I had already done without any incentive. What changed was my belief that government incentives could make things better. They haven't. In fact, they've made things much worse.

We first installed EHR in 1996, after we were scared by an abnormal chest X-ray that was missed due to our paper charting system. We were afraid we were giving bad care for our patients, and saw computers as the solution.

Ironically, our success with our implementation hinged on our non-conformity with our EHR product's design. We didn't care if we used every part of the product, instead focusing on only using things in a way that improved the care without hurting our office workflow.

Early on, we used a hybrid of paper and computers to give us the information in the proper format. Then, once our vendor opened up the product to customization, I totally abandoned the hideous clinical content they had made, designing my own forms that maximized both quality and efficiency.

But last year, our first year in the "meaningful use" era, our focused changed in a very bad way. We started talking more about our EHR complying with criteria than maximizing quality and efficiency. Our vendor jumped on this bandwagon, ignoring the fact that they were stuck in a pre-internet, office-network design, and instead put all of their resources into letting their users meet "meaningful use." In the past, the computers were a tool we used to help our patients; with "meaningful use" they became a distraction, taking us away from a clinical focus and driving us toward proper data-gathering.

This is sadly ironic. We were once using our computers in a meaningful way for the benefit of our patients, but now we are being pressured to abandon the patients in order to qualify for "meaningful use."

This should come as no shock to anyone who has watched American health care over the past 20 years. We have beaten doctors over the head with "clinical pathways," and "evidence-based medicine," all with a good intent: to make sure doctors gave good care. The problem was, however, that these criteria become more important than the patients they were meant to serve. The same is true with our payment system: designed with the initial intent of enabling patients to have access to care, but becoming a behemoth in the exam room, standing between the doctor and the patient.

So what can be done? I don't really know. I still do believe that universal acceptance of EHR, coupled with patient data flowing efficiently between points of care, could improve quality and save a bus-load of money. But I am not so sure about where we are heading. I want to use computers for the benefit of my patients, not for the sake of compliance to the guideline de jour, or the next great government incentive program.

To paraphrase a famous political campaign motto: It's about the patient, stupid.

So I am working to somehow comply with government guidelines (and get my incentive check so I can have a better shot at paying for four kids going through college in the next 10 years) but doing so while somehow not losing focus on the patient. I have to say, it's a very hard thing to do.

My dream of universal acceptance of EHR has turned sour. I am beginning to hate the words "meaningful use." I am starting to fantasize about a life without it, and maybe even a life without anybody else's definition of what the care I give should look like.

I want to be a doctor. I want to take care of my patients. I want them to be the most important thing, not the other people enticing me with their big checks. Can I stay in our system while still giving care that is meaningful?

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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1 Comments:

Anonymous Anonymous said...

Well put, doctor. It's beyond pathetic, as we try to twist and contort our work-flow and clinical interactions in order to satisfy meaningful use and patient-centered medical home criteria. However, it is ultimately hopeless, since the impetus for all of these requirements is data and cost, imperatives which trump and crush the laudatory intentions of well meaning doctors such as yourself. You have a choice: just curse God and die (as Job's friend's advised him) or just struggle to make it from one day to the next, with at least a shred of professional integrity and dignity.

July 16, 2012 at 2:49 PM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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