Color me less than thrilled that the Institute of Medicine is now asking for EHRs to capture additional social and behavioral data as part of Meaningful Use Stage 3. That’s assuming that Meaningful Use is still viable now that the money is nearly gone and more than half of ONC’s senior leadership has left in recent months. Practice administrators have been dazed and confused trying to figure out if they are better off trying to apply for hardship exceptions, take advantage of the flexibility rule, or throw in the towel altogether.
I recently met a practice administrator who swore up and down her providers were attesting for Stage 2, even though they hadn’t yet installed a patient portal and didn’t have a Direct interface. Then again, she also thought that Patient-Centered Medical Home was some kind of design/construction initiative rather than a practice transformation activity, so I shouldn’t have been surprised.
I understand that the Institute of Medicine sees EHRs as a great place to mine data for research, but patients are already weary of having their privacy invaded. Anyone remember the Florida legislation to control whether providers could ask about firearms in the home? My vendor actually had to code in a setting where a practice could hide the firearms questions to avoid running afoul of the law.
Although we’re pushing patients to be more engaged and it’s nice to work with them when they are, at least in my world the majority of patients don’t care about engagement. They just want to be treated and get back to work, their kids, or whatever else was going on in their lives before they got sick. They’re not interested in proactively managing their health when they’re living paycheck to paycheck and think that even questions about alcohol and tobacco use (which are clearly linked to major health outcomes with most people understanding their significance) are over the line.
When we had to start asking about race and ethnicity, we spent on average two to three minutes per patient explaining why we needed that information and helping patients figure out how to answer the question. Many patients thought they were interchangeable, so we were at the front desk educating them on the vagaries of demographic data rather than collecting their co-pay and speeding them back to see the doctor. At least those particular pieces of demographic information don’t change over the life of the patient, so you only have to ask them once.
Now the academic crowd is going to push us to ask about factors that could change at every visit, including depression, education, intimate partner violence, financial resource strain, physical activity, social connections/isolation, and stress. I can tell you without gathering data or an exhaustive chart review that most of my patients would require discussion of the last four.
As a good primary care physician, I should be asking about these things anyway, but I want to ask about them at an appropriate time during an appropriate visit, after I have built a relationship with the patient. I don’t want them turned into screeners that my staff has to administer to every single patient so we can avoid being penalized.
Will providers be judged on the percentage of patients who follow advice to manage these issues, like we’re currently judged on the number of patients we can convince to go for colonoscopies or mammograms? That’s not what I signed up for as a physician. I should do my best to encourage my patients, but didn’t I spend a lot of time in medical ethics learning about patient autonomy and how the paternalistic model of healthcare delivery has to go? We’re just asking for more cherry-picking by providers as they dismiss non-compliant patients from their panels to improve their numbers.
Most patients don’t understand that their data is already being used for research by health plans and other payers without their specific understanding or consent. Sure, it’s probably in the fine print somewhere and it’s either aggregated or de-identified, but if you asked them whether they understand where their data goes or what it’s used for, they would say no. When people think their information might be used in a way they don’t want it to be used (or to be out of their control), they’re going to lie.
Mr. H’s recent poll showed that nearly half of HIStalk readers have withheld medical information from a provider due to privacy concerns. I’m one of them, I admit. Parents are lying on the California home language survey because they don’t want their children labeled as “English learners” for fear they will miss out on other educational opportunities. The old medical school adage of “take the amount of alcohol the patient says he uses and double it” reminds us this is not a new phenomenon.
How about let’s actually get people to use the EHRs they already have and use them well rather than pushing more minutiae on overburdened end users? A friend of mine has an EHR with a great onboard reporting tool, yet hasn’t leveraged it at all for actual clinical care. They’re so busy trying to get their patient portal enrollment numbers up and micromanaging the rest of their “all or none” Meaningful Use metrics that they’ve lost their ability to do cancer prevention outreach, immunization campaigns, or other interventions that have been actually proven to save money as well as improve people’s lives. And that, dear readers, is a shame.
What do you think should be in Meaningful Use Stage 3? Email me.
Email Dr. Jayne.