Wednesday, July 7, 2010

Meaningfulness in Managing Health Information

A new JAMA article published July 7, 2010 entitled "Meaningful Use of Health Information Technology Is Managing Information" explores some of the benefits as well as challenges of electronic health record (EHR) systems and health information technology as it impacts our healthcare system. Written by Richard J. Baron, MD, the article makes some great points about current technology, which also has ramifications for payment reform. Meaningful use will ultimately impact, and could help radically change, the current fee-for-service system.

"The old problem many physicians are trying to solve with an EHR is the efficient generation of a progress note - a document used to justify payment in a fee-for-service system, in which an office visit is the unit of value. This could explain the incomplete adoption of EHRs documented in many studies," Dr. Baron notes.

He gives the example of a 2005 study in which 16% of physicians using an EHR with the capacity to electronically generate prescriptions were still writing prescriptions by hand. He also cites a 2008 survey that defined comprehensive use as using 4 domains of electronic capabilities:
  • recording patient health information and data
  • order entry
  • results management
  • decision support
only 4% of physicians had responded that they were comprehensively using all 4 domains in their practices, and 13% reported only "basic use," ie, using portions of 3 domains."

The author claims that the disparity between potential of EHR systems and their actual use results from
"focusing on the word-processing capacity of EHRs, the only capacity needed if the goal is to produce progress notes documenting visits. One study of the financial implications of EHR adoption in small medical practices found that 51% of the financial return came from more aggressive fee-for-service coding and more frequent use of higher-level primary care billing codes, both supported by more comprehensive documentation. If the goal is to justify billing codes to an auditor, word processing is all that is needed. However, primary care practice poses a different problem: managing the massive amount of information received about patients every day and using it quickly, efficiently, and safely to meet patients' needs. Word processing does not help do that.
An analysis of the work in our primary care office revealed that, on average, there were 18.1 office visits per physician per day. In addition to visits, however, 12.1 prescriptions were refilled, 31.5 laboratory panels or imaging reports were reviewed, and 23.7 phone calls were processed. Each of these activities demands ready access to information. When reviewing a cholesterol test result, physicians need to know if the patient has diabetes, when the last cholesterol reading was obtained and what the level was, what medications the patient is currently taking, and perhaps the patient's most recent blood pressure. If physicians understood their work to be responding safely and efficiently to these requests—none of which generate revenue in a primary care office—they would make very different use of health information technology."
Scanning documents into an EHR does not necessarily provide useful data. Unless data are structured they cannot be easily searched, retrieved electronically or used for trend analysis. Simply moving disparate paper systems into disparate digital systems, without ensuring that the data are useful, does not move us to towards the goal of becoming meaningful users of this technology.
"For instance, in an effort to improve mammography rates, we undertook a project in the fall of 2005 to identify and contact women in our practice who should have had a mammogram but had not. Simply running a report of 'women who had mammograms' was misleading: physicians could electronically sign a mammogram report (time and date stamped) with a single mouse click, the electronic equivalent of initialing and dating a paper report in a chart - a best practice in paper charting. However, to enter the report as structured data (which ensured the EHR database would associate that mammogram with a particular patient on a given date and include it in a report that included all women who did or did not undergo mammography) required a total of 13 mouse clicks. Before this project, physicians were inconsistent about whether they simply signed mammogram reports or performed the additional work of entering them as structured data. After this project, the work flow for mammogram review was changed to assign a clerical person in the office to perform the data entry once the physicians had reviewed the reports.

Similar processes have been adopted for managing colonoscopy results, medication changes made by specialty colleagues, selected laboratory results received on paper, data captured about vaccines administered to patients outside our office, and other important clinical information physicians would like to manage electronically."
Ending on a positive note the article concludes with some hopeful advice for both providers and policy makers:
"As primary care physicians strive to meet the formal criteria, they would be well advised to think about the ways in which EHRs can help them care for patients and solve the practical problems confronted every day, while policy makers and insurers would be well advised to pay for something other than visits and the progress notes that document them. Using information technology to manage information supporting better care of patients will be the most meaningful use of all."