Mysteries of 'meaningful use' deter some physicians from adopting EHRs

November 1, 2010

One part of the healthcare reform package mandated under the Patient Protection and Affordable Care Act includes a measure to give physicians a financial incentive for developing "meaningful use" of their certified electronic health record technology. As I learn more and more about the meaningful use provision, I realize it involves a great deal more than just digitalizing patients' medical records.

Key Points

One part of the healthcare reform package mandated under this act includes a measure to give physicians and hospitals a financial incentive for developing "meaningful use" of their certified electronic health record (EHR) technology. As I learn more and more about the meaningful use provision, however, I realize it involves a great deal more than just digitalizing patients' medical records. In order for a hospital or physician to obtain the proffered financial incentive, the EHR medical record system must be used in a "meaningful" way.

So what does "meaningful" mean? In effect, there are more than two dozen "meaningful use" requirements that healthcare providers need to meet in order to qualify for these financial incentives. In the first wave of "meaningful use" incentives, which begin in 2011, doctors must meet 15 core requirements. In addition, physicians must also meet five objectives chosen from a menu of 10 objectives.

Challenge for some

There are more difficult core requirements that will make meeting the requirement for EHR certification tricky for many solo practitioners. Many of these are obviously designed to serve as quality assurance measures, such as ensuring that the EHR provides the physician with clinical decision support, querying information in the health record relevant to healthcare quality. The exchange and integration of electronic health information with "others" to improve the quality of care and measure clinical quality is but one feature of these requirements that concerns me.

As an example, just this week I received an unsolicited letter from the insurance carrier of one of my patients informing me that "based on claims and prescription data received (by them) that the following observations are made ..." I then went on to read that my patient, for whom I had performed skin cancer surgery only, has "congestive heart failure and should be on a beta blocker and ACE or ARB."

Not only do I not provide treatment for this patient's vascular disease, I don't even know who should be responsible for providing that care. Am I now legally (or ethically) obliged to contact his primary care physician and ensure that the use of these "suggested" medications be considered? Or, hopefully more likely, the primary care physician caring for this man also received the same letter I did, and will consider this suggestion himself. Either way, I feel morally obligated to try to contact this physician and try to find out the status of my skin cancer patient's heart condition.

Many of us who practice in academic medical centers or larger multispecialty groups are very familiar with quality assurance measures, and how to establish and monitor them to determine compliance. However, I doubt many solo practitioners have the personnel and time to establish and use these same measures to monitor some aspect of the quality of care being provided in their offices.

Perhaps meeting some of these "core requirements" may not be as onerous as they seem at first blush, since I can see how they could be automatically performed by the software sold by the many companies that are marketing their products for EHR. On the other hand, if establishing the measures to permit certification of their EHR and obtain the promised financial incentive requires the investment of a significant amount of physician time - or even the need to hire additional personnel - how are these requirements going to be cost-effective?

Trust me, I'm all in favor of delivering the highest quality of care possible. However, disguising the issue of assessing quality under the requirements for EHR is not only not unfair, but, in my opinion, also a flagrant abuse of the funds that were appropriated under the American Recovery and Reinvestment Act.

Privacy concerns

I also agree with the public's concern about the potential loss of confidentiality of their medical records as a result of the introduction of these new requirements. It seems to me that to get physicians to record personal medical information electronically and somehow share it with others who are going to assess the quality of care being provided also opens the door for this type of loss of confidentiality.

While I can see some benefits from this program, I am not sold on the idea that EHR is the answer to problems like improving access to healthcare for millions of uninsured Americans or the implication that one can increase the efficiency of providing healthcare by using digital records over paper ones. I fear the "meaningful use" requirement will add another layer to the healthcare bureaucracy and potentially cost many people their privacy as it pertains to their health history.

Ronald G. Wheeland, M.D., is chief of dermatologic surgery, Department of Dermatology, University of Missouri, Columbia, Mo.