Eyes Wide Shut – Is This Meaningful Use?

Again and again, I find myself expounding upon the need to differentiate between the “letter of the law” and the “spirit of the law” of Meaningful Use Stage 2. I believe whole-heartedly in the transformative power of health IT, and support the future vision of the Meaningful Use objectives of patient empowerment and nationwide standards for records transmission and interoperability. The spirit of the “law” is a revolutionary movement towards a technology-enabled, patient-centric healthcare system, where clinical data can be shared and consumed instantly, whenever patient desires or requires it.

The letter of the “law” is daunting, and its implementation could be seen as not only counter-revolutionary, but detrimental to the very patient population it is designed to engage and empower.

Consider this acute care scenario:

You’re a hospital healthcare provider, discharging a patient, in compliance with the patient-specific education and Summary of Care measures. You log in to your EMR, complete the discharge instructions in the correlated workflow, print the discharge summary and any condition-specific educational information for the patient, revisit their room to insure that they can review the instructions and ask any questions, and you’re on to assessing the condition of the next patient in need of care. Right?

How many times did you have to close the “patient-specific education” suggestion windows that popped up, alerting you to available materials for download, keyed off diagnosis codes or lab results?

How many minutes did you spend looking for the HISP address of the patient’s cardiologist, so you could transmit the Summary of Care document to them via the Direct module of your EMR? How many clicks did you have to use to FIND the Direct module in your EMR? And how many minutes did you spend cursing the ONC for requiring Direct for Summary of Care transmission for 10% of your discharged patient population when the cardiologist’s address was rejected by the Direct module, giving you a message that the receiver is not DirectTrust-accredited?

How much time did the discharge process take you before your facility decided to attest to Meaningful Use Stage 2? How much time does it take you now?
Consider this ambulatory care scenario:

You’re support staff for a general practitioner, who is deploying a patient portal in support of patient engagement measures. At check-in (or check-out), you provide the patients with the URL for enrollment and access, give them information on the benefits of having their medical records available electronically, encourage them to communicate electronically with their provider with questions or concerns, and you send them on their empowered and engaged way.

How many minutes did you spend validating each portal account owner’s identity once their enrollment request came? How many minutes did you spend validating the relationship of the portal account owner to each of the patients he/she requests to associate with the account? How did you document the due diligence done to insure no medical records are improperly released per HIPAA and other federal guidelines, as in the case of custodial disputes, behavioral health patients, or emancipated minors?

How many minutes did you spend walking patients through the enrollment, login, medical records view, and secure message functions? How much time did you spend answering questions from patients about the portal, rather than the health concerns that prompted the visit?

How much time did the check-out process take before your GP decided to attest to Meaningful Use Stage 2? How much time does it take you now?

In both of these scenarios, did you or the patient see any measurable difference in care as a result of the EMR’s new functionality?

Now, consider the aggregate of these scenarios over an entire day – dozens of encounters, dozens of clicks, dozens of minutes spent engaging the EMR to record requisite “clicks” for attestation numerator reporting, rather than engaging the patient.

Is this meaningful use of a healthcare provider’s time and energy? Is this meaningful use of health IT, meeting very specific targets to obtain finite objectives rather than enabling innovation and deriving best practice long-term solutions?

Is this what the ONC intended?

About the author

Mandi Bishop

Mandi Bishop

Mandi Bishop is a hardcore health data geek with a Master's in English and a passion for big data analytics, which she brings to her role as Dell Health’s Analytics Solutions Lead. She fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.


  • These are common, godawful experiences. Common in the sense that lousy software does these kinds of things all the time. However, this nerve wracking behavior has nothing to do with the MU’s substance anymore than my ISP’s site constantly logging me into my account has to do with my cable service.

    In the short run, you should be able to vociferously complain to a vendor whose software is so hostile. In the long run, users, as a class, need to make it clear that crappy usability is not acceptable.

  • Its not so much spirit vs letter, its hope vs reality.

    We all have an idea of what good HIT can do. We all know what that the current set of EHRs can’t deliver on that “Hope”.

    Unfortunately, making everyone use EHRs today so we will be ready for good HIT in the future, is like saying we should make everyone use a minivan today so we will be ready for high speed rail in the future.

    This is a $40,000,000,000 problem.

  • Very well written John. The underlying important question I got out was…’did you or the patient see any measurable difference in care as a result of the EMR’s new functionality?’

    I think there will be no positive difference in care if there is waste of time – clicks, education and explaining – on a SUSTAINED basis.

    We all know learning EMR takes a while, but after that, the graph should get better, and in most cases it does. Staff gets productive (I can’t say the same thing about providers).

    Similarly, if time spent on educating patients results in saving of time overall (over a period of time), then you start focusing on better care delivery.

    But initially it will consume a lot of time and effort. So, practices should keep track of the time spent. At the end of, say, 6 months, if you are still in the office late hours and still seeing less patients, then there is no hope.

  • Hello John,
    Be Careful. You are talking about reality. We have begun to work way too much for computers. Computers were supposed to make things better, faster and easier for us and our patients. Not the other way around.
    Gil Carter, MD
    Ten Second Medical Record TM

  • Reality check: Something with the Orwellian name “Meaningful Use” is supposed to result in a net positive for health care?

  • I agree with the MU-induced work flow interruptions, but also agree that it was very appropriate to set measurable targets considering the substantial EHR incentives under ARRA. In a perfect world, we could have just distributed the incentives on a promise that each recipient would do their best at “enabling innovation and deriving best practice long-term solutions”… But would everyone make the same efforts? Would all recipients even install the EMR?

    Were the mandated measures not the correct ones? Plenty of bright folks worked on this before the final rule was issued.

    I believe the challenges can / will be resolved by a combination of better software design AND shifting more tasks to non-clinicians (which may even require “scope of practice” legislative changes). And even so, some patients provide more accurate information when it is the Provider rather than a medical assistant asking certain sensitive questions…so that moving some time-consuming tasks away from the Provider can negatively affect the accuracy.

    I guess if I had all the answers I wouldn’t still be looking for my next project…

  • Such thoughtful comments! Let me reiterate again that I believe in the spirit of MU: providing the framework for true interoperability and freedom of health data to flow from providers to patients to plans, empowering care coordination and treatment efforts, and providing patients the data-driven ammunition to engage in a meaningful way. Viva la healthcare revolution!

    Unfortunately, what I see in practice is the inability of the healthcare system to adopt to the rate of change expected from technology, and the ostrich-like behavior of the entities insisting upon that rapid change adoption when they are faced with the reality of the consequences.

    “Rip and replace” is a consistent drumbeat from several EMR vendors, and that strategy may be valid for a small provider practice. But the rate-of-change issue is endemic in the system, as a whole, which consists of all manner of organizations and networks, large and small; this “get rid of what’s not working and start over” strategy cannot be employed in larger environments without SIGNIFICANT risk to the patient population due to workflow disruption.

    Honestly, I’m just glad I’m not a clinician…I’m just a geek! 🙂

  • Wow, we really have become the immediate gratification generation. How much time did you spend learning to ride your bicycle. Was it the bike manufacturers fault that you couldn’t ride it without training wheels the first time you jumped on? Was it the bike manufacturers fault that you skinned your knee or elbow when you fell.

    Why does this entire industry take no accountability for their own learning curve. ONC created requirements that build the foundation for drastically improving healthcare. I hope we can all agree this is an industry that has some room for improvement. ONC did not and could not create requirements that took everyone from tricycle to BMX on their first attempt.

    Ask any patient who has had to drive back to a specialists office to pickup paperwork that was intended to be faxed before they arrived and they will quickly tell you these changes, once running smoothly, are welcome. Curiously, now that ePrescribe tools have evolved, I don’t hear a lot of complaining about this part of the process. Patients who picked up their prescription at the pharmacy after their physician sent this electronically can begin to see the merits.

    It is true, learning often requires pain. Both a skinned knee while riding a bike or carpal tunnel syndrome brought on by the three extra clicks needed to send a direct message to a cardiologist is painful. However, we are quickly forgetting the paper cuts inflicted by the fax machine and the dirty shirt inflicted by the copier.

    Times are a changing. MU creates the destination. Each provider will need to work through their best path. Some will choose to stay home. Some will love the trip. Either way, this has the potential to become a fulfilling adventure.

Click here to post a comment