Simple Proof that EHR and Meaningful Use are Burdens

February 10, 2014
Daniel Essin, MA, MD

EHR is a burden, and as such, there should be evidence of effectiveness before it is imposed upon physicians and medical practices.

The editors of the Journal of the American Medical Association (JAMA) and the BMJ (formerly British Medical Journal) have been proponents of evidence-based medicine (EBM) for some time. Over the years, they have become friendly with the "pioneers" in the field and recently got them together for a retrospective. The video from JAMA and the editorial from BMJ are worthy of your attention. I must admit, that to someone equipped with a scientific frame of mind and a healthy dose of skepticism, it always surprised me that what the EBM people were promoting wasn't the norm.

If there is one thread that unites my approach to EHR it is: Show me the evidence that it is safe, effective (does what you expect and produces beneficial results), and worth the time and money that are devoted to it. Also, what is the opportunity cost? What else could have been done differently or better if not consumed with trying to conquer an EHR.

Frankly, and despite our fervent hopes regarding benefits that seem obvious, there is darn little solid evidence as even the people at RAND who make glowing predictions in 2005 were forced to admit [Arthur L. Kellermann and Spencer S. Jones, "What It Will Take To Achieve The As-Yet-Unfulfilled Promises Of Health Information Technology," Health Affairs, 32, no.1 (2013):63-68].

Let's look at some evidence related to burden. Wiktionary defines burden as a.) A heavy load; b.) An onus; and/or c.) A cause of worry; that which is grievous, wearisome, or oppressive. Given the definition, one could stop here. EHR is a burden. If it's a burden that is all the more reason that there should be evidence of effectiveness before the burden is imposed.

Now let's look at what the government has to say about other burdens, specifically those relating to paperwork. An EHR is intended to be an electronic substitute for paper so, logically, the Paperwork Act and its requirements should apply to any EHR regulation. The Electronic Code of Federal Regulations, Title 5, Part 1320 - Controlling Paperwork Burdens on the Public, §1320.1 says: "The purpose of this part is ... to reduce, minimize, and control burdens and maximize the practical utility and public benefit of the information created, collected, disclosed, maintained, used, shared, and disseminated by or for the Federal government."

There is plenty of anecdotal evidence that EHRs promote inefficiency, slow the flow of patients, and cost billions. This can hardly be called "utility." In case you're wondering, I am more willing to accept anecdotal evidence of problems that I am of "success" for one primary reason. In both cases people are straining to make the EHR "work." A success in the face of extraordinary effort cannot simply be attributed to the EHR itself for it was not working to start with, hence the need for extra effort. Failure and dissatisfaction also occur in the face of this same effort, only in these cases, heroic life-sustaining interventions were not enough. The EHR itself was so fraught with problems that even superhuman efforts could not overcome them.

So much for utility. How about public benefit? Well ... the claims that EHR and the meaningful use exercise will benefit the public are just that - claims;  a hypothesis. The government is conducting a Phase III clinical trial of a medical modality without going through Phase I and Phase II. It's a crapshoot but maybe it will succeed. The problem is, there is no study design, no protocol, no tracking of things other than attestation and meaningful use reports. Any claim of success will remain as unsupported by evidence as it is now.

The requirements under the Affordable Care Act give every evidence of being a burden. They give little conclusive evidence of benefit. There are few criteria for what would constitute success. What is the evidence for that? Chest Physician [vol. 9, no. 1, January 2014] reported that the "earliest that physicians will progress to Stage 3 of the meaningful use requirements will be in January 2017. Officials at CMS are still developing the Stage 3 requirements and expect to issue a proposed rule sometime in the fall of 2014."

So, no clear utility and no clear benefit yet an onus and a cause of worry. It certainly violates the spirit, if not the letter, of the Paperwork Reduction Act. If it walks like a burden and talks like a burden, it's a burden.