Tying EHR Proficiency to Physician Licenses Flawed

January 5, 2015

Massachusetts' effort to tie license renewal to meaningful use of an EHR is a great way to ease the physician shortage.

Every year, I faithfully satisfy my continuing medical education (CME) requirements, not just because it's required but because it's important to me. The operant word in CME is "education" which, as I understand it, means keeping my medical knowledge from going stale. Every two years, the hospital wants to know that I've met the minimum requirements for CME. They also review/renew my privileges, if they are satisfied that I am still competent. If I haven't done any craniotomies in the past two years, the committee is going to wonder if my skills might have gotten a bit rusty. They would probably require that I be proctored for the next half-dozen procedures. Of course, they'd also want to know if I've ever done a craniotomy. They are simply not going to accept my three hours of CME on various aspects of neurosurgery and craniotomy as evidence of proficiency.

They want to know both that I know what to do and that I know how to do it; in other words my knowledge and my proficiency. For U.S .Coast Guard Commandant Admiral Robert J. Papp, Jr. proficiency consists of:

• Training, education, qualification, and certification

• Advanced knowledge, experience, and seasoning

• Self-discipline and voluntary adherence to a set of rules or governing standards

• Sustained drive to achieve higher levels of excellence

• The continuous pursuit of mastery of craft

I learned today that "The Board of Registration in Medicine (BRM) has finalized regulations that implement a [Massachusetts] state law requiring physicians to demonstrate proficiency in the use of electronic medical records, as well as the skills to achieve the federal meaningful use standard."

They're using a novel definition of proficiency:

•You've attempted to meet the meaningful use requirements or,

• You have some relationship with a hospital that has been meaningful use certified or,

• You've done 3 hours of CME on EHR or,

• You are participating in or are authorized user of the Massachusetts Health Information Highway (the state’s official health information exchange).

Unlike the Coast Guard's definition of proficiency, which is meaningful and measurable, under the BRM definition you don't actually need to know anything or know how to do anything.

In Los Angeles, try as I might, the credentials committee will simply not accept my three hours of neurosurgery CME as evidence that I am proficient at cracking skulls. But all may not be lost. Those three hours might satisfy Massachusetts, under their new definition of proficiency. Who knows? I could be well on my way to developing a thriving neurosurgery practice in Massachusetts - if I don't kill too many patients.

But really, what were they thinking?

It's easier to develop proficiency at things, like driving, because most cars work the same way. Your experience is cumulative; same for microwaves, circular saws, coffee pots, and stethoscopes. EHR is another story. Epic doesn't work like Cerner. Cerner doesn't work like Allscripts. Allscripts doesn't work like Vista. Etc., etc., etc. And none of them work very well.

Even for arcane, one-of-a-kind things, one can become proficient (even expert) with 5,000 hours to 10,000 hours of adhering to Adm. Papp's approach.

Only a few dedicated, determined physicians ever become truly proficient at using an EHR. The rest learn the few functions that they need to get through day and leave it at that. There is no time to do more. The EHR typically consumes the three hours of "free" time that physicians might otherwise devote to their proficiency every day.

This leads me to wonder:

• Why make EHR proficiency a condition of licensure?

• How would you assess actual proficiency? (Probably by requiring the equivalent of a driving test - if you can get around the HIPAA issues, and can pay all the examiners.)

• How does the reasoning behind the BRM definition of proficiency differ from the notion that maintenance of certification insures competency (a proposition that regulators also think is self-evident but which physicians all over the country question).

If we take this to its illogical extreme, perhaps we can replace the traditional four-year medical school with three hours of CME-like activity, or maybe, just working for someone who has a medical license. Doctors could be minted in record numbers, virtually overnight. That would go a long way to easing the doctor shortage - and they could be paid less; they won't be burdened by huge debts. Of course, you get what you pay for, but people do so love the idea of a bargain.

So I guess, in the end, we should thank Massachusetts for its great idea.