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Say you are a pediatrician in an average middle class lily white suburb and most of your little patients are either sitting stiffly in the pews next to you or are elevating your spirits with angelic voices clad in white robes on a blessed Sunday morning. Say little Johnny trips on his way down the altar and ends up taking a ride to the ER to have his forehead stitched. Does the ER doc need to know that the 13 year old altar boy is not a smoker? Does he need to know that Grandpa Joe died from prostate cancer, but other than that the family history is unremarkable? Does the nurse washing Johnny’s forehead need to be informed that the boy has a history of ear infections and had tubes put in when he was 3 years old? Not a fair example, right? Let’s cross the 8 Mile road and look at another Johnny who shows up at the other ER at 2 am with two gunshot wounds to the chest. Does anybody on his care team gives a damn about Mom suffering from depression and diabetes, or the fact that Johnny is a current smoker of tobacco products and has been counseled on cessation? Yes, I know, sometimes these things are pertinent, and sometimes even more details are needed, but not always, and not always the same details. Unfortunately, we are busy building a one-size-fits-all-circumstances infrastructure, which is destined to be too big for most, too small for some and ill-fitting for all but a random handful.

Leaving aside the troubled business side of medicine, electronic medical records are supposed to ease and simplify the capture, analysis and sharing of clinical information, by utilizing computer software tools. Computers have eased and simplified the capture, analysis and sharing of financial information, supply chain information, manufacturing information, transportation information, and every other type of industrial information you can think of, so why not medical information? Before you go pointing out that clinical information is highly variable and so very unique to the individual, please consider that computers have simplified and eased capture, analysis and sharing of personal information of all sorts from chatting and accessorizing outfits, to making friends and asking a pretty girl out on a date. Surely, nothing is more unique and personal than finding your soul mate. Not even health care.

If a physician practicing medicine in the U.S. today desires to ease and simplify the capture, analysis and sharing of clinical information, he or she can choose from a large assortment of computer software tools, better known as EHRs, all carefully examined and certified by government sanctioned entities to be capable of easing and simplifying these tasks, and as Pete Seeger might have said, “there's a green one and a pink one and a blue one and a yellow one, and they're all made out of ticky tacky and they all look just the same”. To the dismay of regulatory and certifying authorities, most physicians who are willy nilly adopting these tools, under threat of financial fines and penalties, continue to grumble that the capture, analysis and sharing of clinical information is neither eased nor simplified by EHRs, and quite the opposite is true.

This strange situation can be, and often is, dismissed as due to physicians being technophobes or just unwilling to do their share in promoting beneficial health reforms. To support these specious arguments, the regulators are constantly parading a handful of doctors who found happiness and efficiency in their EHRs. Unexplainable? Not really. There are always a few lucky folks for whom one-size tee shirts fit as perfectly as if the rag was tailored just for them, while the rest of us have to tuck it in, tie it in the back, cut it off, or pull at the sides to make it stretch, and in all cases it ends up looking like someone else’s garment. A quick look at what is driving health care costs up reveals that physicians as a group are cheerfully adopting things like magnetic resonance, computed tomography, image guided radiation, proton beam therapy, laser surgery, robotic this or that, and a host of other high tech tools that would terrify the average technophobe into crawling under the first available rock. So why is health information technology so different? Or is it?
  • epocrates, the drug reference software boasts 50% of physicians in the U.S. as its users. epocrates has been steadily growing since 1998 and is practically a household name when it comes to medications advice. It is available on iPhones, iPads and mobile Android devices and it has expanded far beyond just lists of indications and contraindications for prescription drugs.
  • UpToDate needs no introduction either. The widely used electronic clinical decision support system has been in existence for over 20 years and you would be hard pressed to find an academic institution that is not subscribing to its content and tools, both in the U.S. and the rest of the world. Like epocrates, UpToDate is available on the web and on all fashionable mobile devices.
  • Doximity is a relatively new kid on the block, and a very interesting one to boot. Only 3 years old and already claiming to have “crossed the 200,000 member milestone”. Doximity is a communications platform for physicians allowing members to securely exchange messages, including clinical information, and make referrals or obtain ad-hoc consultations from colleagues. Sort of like a social network on steroids, and of course it is available on mobile phones and tablets too.
epocrates never bothered to obtain Meaningful Use certification for its main product, because what it does and what clinicians find useful is not a certifiable activity. It did however certify its feeble attempt at creating yet another ticky tacky EMR, and then proceeded to quickly dump the resulting stillborn. UpToDate obtained certification only for its peripheral patient education module, and Doximity is nowhere around the target zone of what the government decrees as meaningful use of technology. While both epocrates and UpToDate had ample time to solidify their user base before the advent of Meaningful Use, Doximity experienced its meteoric rise in spite of Meaningful Use and that should give us some hope that any day now, a couple of MIT grads in some basement may launch Patximity and make information sharing between doctors and patients as simple and as easy as apple pie. We can imagine that somewhere far from the limelight a doctor laboring in solitude will come up with the simple and easy to use Charximity to effortlessly capture thought processes at the point of care. And then someone will come up with something better or different or faster or smarter or cheaper…

Sadly, this crescendo of innovation is very unlikely though, because unless the new software is a clone of some primordial EMR, or parts thereof, and unless it conforms to government devised ways of doing things, most prospective customers will be forced to choose between a new and unknown product and the piles of cash thrown at them by regulators. If say, our imaginary Charximity developers come up with a quick and elegant way to record a dynamically defined set of information, and package it in a small, nimble and universal format that lends itself to being securely moved around the private networks of the fabled Patximity and real Doximity, in a most expedient way, chances are great that this cool innovation will fail to thrive because it can’t inform regulators on Johnny’s smoking status or Grandpa Joe’s prostate trouble, in an exhaustive XML format passed around through interminable chains of certified intermediaries on the federally secured national health information network. The good news is that one day checkboxes and dropdown lists will only exist at the Smithsonian, and good technology will prevail in the end. The bad news is that the end is being pushed further and further away with each additional Meaningful Use stage.

Alternative Health Information Technology

It’s that time of year again when Meaningful Use conversations heat up because all sorts of deadlines are approaching, and as expected, nobody is ready. Meaningful Use was originally intended to have 3 stages, each lasting two years. At the end of 2011, Meaningful Use Stage 2, which should have started in 2013, was postponed by one year and reduced to 90 days to allow vendors and providers enough time to build, deploy and implement new functionality required for Stage 2. As 2013 is drawing to a close and Stage 2 is practically upon us, a flurry of organizations is petitioning the Secretary of Health and Human Services (HHS) to delay Stage 2 just a little bit longer.

The College of Healthcare Information Management Executives (CHIME) fired the first shot back in May, asking for one more 12 months extension. Later in July, the American Medical Association (AMA) and the American Hospital Association (AHA), combined forces and jointly requested additional flexibility to be built into Stage 2 and that providers that are still at Stage 1 should not be forced to upgrade their software in 2014 (more on that below). The American Academy of Family Physicians (AAFP) followed with its own sophisticated proposal on how to better stagger the transition to Stage 2. Next, the Medical Group Management Association (MGMA) petitioned the Secretary to place a moratorium on all penalties for providers that achieved Stage 1, and to allow Stage 1 meaningful users to continue attesting for Stage 1 if they cannot obtain a Stage 2 certified product. HIMSS, the EHR vendors association, sent their letter in support of maintaining the current Stage 2 Meaningful Use launch schedule, but extend its first year to be 18 months long. Confused yet? Let’s detangle the mystery.

First and foremost, whether you began your Meaningful Use journey in 2011 or are about to jump in next year, this conundrum affects you directly, because beginning January 1st 2014 all meaningful users must implement and utilize 2014 certified EHR technology (CEHRT). Even if you plan on just attesting to Stage 1 next year, you cannot use just any old 2011 certified EHR. So all 300,000 or so eligible professionals who have previously attested to Meaningful Use Stage 1, plus all late adopters planning to enter the fray in 2014, will be out there trying to wrestle a good place in line for upgrades, training and installations. Most will do so only after January 1st, and all will have to be ready to start clicking the boxes no later than October 1st. That’s over 1,000 clinicians per day, not counting new entrants. Any way you want to look at it, it’s not a very likely scenario.

Much has been said in the various letters to HHS regarding the small number of EHRs that managed to get certified for 2014, compared to the seventeen hundred complete EHRs certified for Stage 1. This is true, and this may pose a completely different type of problem down the road when doctors realize that most of these fly by night products will soon disappear. However, as late as October 2010, we had less than three dozen certified complete EHRs for Stage 1, a number that grew exponentially in the following couple of years. My guess would be that by the end of the year all major, midsize and viable minor players will be 2014 certified. The problem this time around is that Meaningful Use Stage 1 has been rather successful and there are now about 6 times as many providers needing a new EHR as there were in 2011, and unlike 2011, those who fail to get their upgrades in time will not only lose an incentive, but will be financially penalized by CMS. It just doesn’t seem fair.

Delaying Meaningful Use Stage 2 by yet another year will obviously address the time crunch problem, but if we really want to be fair, we have to admit that another delay will look really bad for the program. Putting in place a complicated scheme of who should buy what and when, and who should attest to which Stage at which time, in an attempt to control the flow of upgrades, is bound to create much confusion in an already over specified and (needlessly) complex EHR certification scheme. So what should HHS do? Take another hit to its credibility and further delay Stage 2? Push forward full steam and deal with the consequences at a later date? Perhaps Meaningful Use is more like a Chinese finger trap at this point, and the best strategy would be to relax a little bit, and understand that 5 year plans rarely go as planned and that’s OK. Below is a humble suggestion to that effect. (Note: Here we are discussing the Eligible Professional measures. The Hospital equivalent should be straightforward.)

Meaningful Use Stage 2 Beta

There are three factors affecting the Meaningful Use program trajectory: time frame, requirements definition, software readiness. Unfortunately, we started by defining the time frame and then discovered that requirements definition and software certification did not fit in our predefined schedule and not even in our expanded schedule. Also unfortunately, we cannot control software readiness, since it depends on thousands of independent players that we can motivate, cajole or threaten, but that’s about it. What is left then? The requirements. The definition of Stage 2, or any other Stage, is not immutable even at this late junction. Those who made the rules can change them ever so slightly to allow a hybrid Stage 2 Beta (see figure below) to be inserted between good enough and perfection.

Proposed Meaningful Use Stage 2 Beta vs. Current Meaningful Use Stage 2 (click image to enlarge)


When compared to Stage 1, Meaningful Use Stage 2 introduced 4 types of changes:
  1. Higher thresholds for existing measures
  2. Transition of optional (Menu) measures to required (Core)
  3. New measures (Menu and Core) for existing EHR functionality
  4. New measures that require new software to be built (Menu and Core)
The changes in #1 and #2 can be all satisfied with 2011 CEHRT. #3 can be satisfied by most 2011 CEHRT, and even some of the #4 measures are already deployed in the better 2011 CEHRT. Splitting and transitioning portions of a handful of #3 and #4 measures from Core to Menu, will allow the 300,000 providers that already attested to Stage 1, to seamlessly move on to Stage 2 Beta without much turmoil. All in all we are talking about 5 such changes from Core to Menu, plus allowing for the increased number of clinical quality measures to continue to be submitted through attestation if necessary.
  1. CPOE for labs and radiology capabilities were present in all good EHRs long before ONC certification came into play.
  2. Patients access to health information is, by definition, what patient portals are for, and many 2011 CEHRT used portals to become certified. True, ability to download and transmit information is rarely there if at all, but although this is a 2014 certification requirement, it is not a Meaningful Use actual requirement.
  3. Having the EHR suggest education materials based on patient health status has been around for a decade, and the better 2011 CEHRT already have that built in.
  4. Secure messaging through a patient portal is part and parcel of any patient portal. More exotic forms of messaging which are required for 2014 certification are optional for users (same as #2).
  5. Electronic health information exchange is only available for a minority of users, for reasons other than EHR capabilities, which should have been present in all 2011 CEHRT.
  6. Electronic submission of clinical quality measures is possible from 2011 CEHRT that have a CMS approved registry. There aren’t that many and insisting on the methodology here seems a bit petty.
The proposed Meaningful Use Stage 2 Beta is achievable with 2011 CEHRT, and allowing it to be used along with the 2014 CEHRT for an interim Stage 2 Beta, should provide immediate resolution to the problem at hand. Since most 2011 CEHRT contain functionality to meet the problematic measures anyway, my guess would be that these newly designated Menu measures will be very popular with Stage 2 Beta attestations, particularly because many of the current Stage 2 Menu measures are heavily dependent on non-existing third party infrastructure. And just so CMS doesn’t feel that it is giving away too much by allowing 2011 CEHRT to be used for a slightly less stringent Core set, let's up the ante on the Menu measures and require that 5 are satisfied instead of the current three. If I was working on Meaningful Use 2 Beta, I would pick the first 4 items above, plus visit notes or family history from the current Menu items (no decent EHR comes without notes and histories).

The difficulty with this Meaningful Use Stage 2 Beta proposal is that all downgraded measures have something to do with the much debated subject of interoperability, thus Stage 2 Beta could be erroneously construed as a retreat from interoperability in general, and so called patient engagement in particular. It may be so, but to a very small degree, since there is no way to pick 5 Menu items without having at least 3 of them relate to interoperability/engagement. Besides, it is usually better to continue moving ahead at a slightly slower pace than it is to come to a dead stop, or alternatively keep going fast and furious over the impeding cliff. Personally, I would use the Beta period to evaluate the program to a greater degree than just how much money was paid out in incentives, and I would take a hard look at the incredible complexity introduced in the EHR certification program, because this too frequent and too invasive granularity is not sustainable, and is the root cause for the difficulties we are experiencing right now.

Meaningful Use Stage 2 Beta - A Suggestion

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