Trendspotter: Meaningful use criteria may not suffice for care coordination

By Ken Terry
The Department of Health and Human Services (HHS) has released draft regulations on the “meaningful use” of electronic health records that will be required to qualify for government incentives in 2011. The good news is that physicians will not have to enter visit notes electronically to show meaningful use. But you will have to use some other EHR features out of the box, including electronic prescribing and decision support tools such as drug interaction alerts.

Patient demographics, vital signs, and smoking status must be recorded in the EHR, and at least 50 percent of lab results will have to go into the EHR as structured data. That means you will need interfaces with your major labs. In addition, you will have to give patients access to key data from their medical records, and you will have to transfer clinical summaries as part of referrals. In addition, you must either submit quality data based on PQRI measures and other metrics endorsed by the National Quality Forum, or attest that you can do so. In 2012, you will have to send in the data electronically.

All of this, of course, is designed to prove that physicians who apply for up to $44,000 in Medicare incentives ($64,000 for Medicaid) are using their EHRs in a way that will improve the quality, safety, and efficiency of patient care. A key part of that quality improvement is enhanced coordination of care — a major goal not only of the HITECH Act, but also of the public and private medical home pilots that are underway.
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But a new study from the Center for Studying Health System Change casts doubt on whether current EHRs, even if they meet meaningful use criteria, are up to the task of improving care coordination in today’s environment.

Based on their interviews with users of EHRs (which they call EMRs) in 12 markets, the CSHSC researchers conclude:

“There is a gap between policy-makers’ expectation of current EMRs’ role in the coordination of care and clinicians’ real-world experience with them. We found that commercial ambulatory care EMRs facilitate care coordination within a practice by making data available at the point of care, but they are less helpful for exchanging information between practices and settings. EMRs may also have unintended consequences for coordination, such as creating an information overload that complicates providers’ efforts to discern key clinical information.”

There are some non-technological reasons for these shortfalls, including physician culture and a lack of reimbursement for care coordination. But the researchers also delineate some deficiencies that affect some or all EHRs. Among them are these:

• A lack of interoperability between systems used by various physician practices, hospitals, diagnostic testing facilities, and other providers. This results in practices scanning paper documents into the EHR as non-searchable PDF files.
• Problems with problem lists. Few EHRs link specific problems to portions of past notes that address them. Also, the lists often include redundant diagnoses generated by test results.
• Inability to capture the planning component of medical-decision making. EHRs typically do not remind physicians of things that need to be done for patients until the doctor opens that patient’s chart for the next visit.
• Lack of registries or other mechanisms that would facilitate population health management, ensuring that patients with particular conditions receive the preventive and chronic care they need when they need it.
• Inability to track referrals within the EHR.
• Tendency to generate too much information in referral notes, making it difficult for physicians to find the important points about a patient’s care.

The CSHSC researchers suggest that HHS use its meaningful use and EHR certification regulations to prompt vendors to correct these and other deficiencies in their products. The 2011 meaningful use criteria indirectly address some of these issues, such as interoperability, referrals, and population health management. But they are not specific about the technology tools that are needed. Neither are the accompanying standards and EHR certification criteria, which are designed to support the meaningful use requirements.

One reason why the rules are not more specific is that HHS and its advisory committees wanted to avoid requiring certain types of functionality, fearing that that would limit innovation and favor established vendors. In addition, it is clear that the government does not want to require EHRs that might prove too complex for the majority of physicians. In fact, doctors are even allowed to combine several components from different vendors if those enable them to show meaningful use.

This might be an acceptable starting point if the only goal were to persuade the bulk of physicians to adopt some kind of EHR. However, the implementation of any kind of EHR — other than a basic electronic chart — requires a big investment in time and money. If physicians are going to go to all this trouble, the least that the vendors can do is provide them with the tools they need to meet the government’s goals.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." In his weekly Trendspotter column, Ken is looking out for trends and changes that may affect your practice.