By now, unless you’ve been living inside a cave, and are a physician, you have heard about “meaningful use” of the EHR. Meaningful use refers to a set of 15 criteria that medical providers must meet in order to prove that they are using their EHR as an effective tool in their practice.
There are 10 additional criteria that are considered a la carte menu items, from which only five need to be demonstrated by the medical provider. In total, each provider must complete 20 meaningful use criteria to qualify for stimulus payments during stage one of the electronic health reimbursement, or EHR incentive program.
Here are the 15 required criteria and the thresholds to be met:
Demographics: 50 percent
Vitals: BP and BMI 50 percent
Problem list: ICD-9-CM or SNOMED — 80 percent
Active medication list: 80 percent
Medication allergies: 80 percent
Smoking status: 50 percent
Patient clinical visit summary: 50 percent in 3 days
Hospital discharge instructions: 50 percent - or - patient with electronic copy — 50 percent in 3 days
e-Prescribing: 40 percent
CPOE: 30 percent including a med
Drug-drug and drug-allergy interactions: Functionality enabled
Exchange critical information: Perform test
Clinical decision support: One rule
Security risk analysis
Report clinical quality: BP, BMI, smoke, plus three others
Since my cardiology group has had an EHR since 2004, a lot of this has become routine and easy for us. And although I am a big proponent of the EHR, I am not an advocate of meaningless rules and criteria, which do nothing to promote improved patient care, in order to be reimbursed or "incentivized" by Medicare. Following are two cases in point.
One of the criteria calls for listing the patient’s smoking history and how you have advised him to quit smoking, if they are active smokers. Most of my patients fall into two categories — they either quit smoking years ago or they are active smokers with little motivation to quit. Nonetheless, in the latter group, I must document on each visit that I have counseled them to quit smoking and their acceptance or rejection of smoking cessation advice. Since the inception of this rule in our EHR program, I would estimate that less than two-dozen patients have consented to join our "smoking cessation" clinic. If they don’t want to quit the first or second time I doubt they will by visits 20 or 30. Patients quit when, and if, they are ready to quit. I have yet to meet a patient who doesn’t know that smoking is bad for their health.
The second one is likewise absurd. We must document the patient’s body mass index (BMI) on each visit. While I feel documentation of this is useful, the requirement that they be counseled every visit to lose weight, is a waste of time. There is no more vexing problem encountered in most physicians’ offices than our failure to help patients lose weight in a safe fashion — and this is not from lack of trying. Data suggests that few patients are willing to adopt real lifestyle changes in order to lose weight. Most just want a magic pill or surgery. The majority likely has more interest watching “The Biggest Loser” on television than listening to me preach.
This is, in a nutshell, what is wrong with evidence-based guidelines and mandates. Like most government ideas, the initial intents are lofty and beneficial. However, once mid-level bureaucrats make decisions on how to implement these rules, the end result is more non-productive work for physicians and little, or no, improvement in quality of care for patients.
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