Curbside Consult with Dr. Jayne 10/24/11

A reader recently sent me a link to a blog by Dr. Joe Heyman titled We Can’t Fix All of Medicine with Meaningful Use. He calls out two serious problems with Meaningful Use – measurement for the sake of measurement and the introduction of unintended frustrating inefficiencies that offer no noticeable improvement in patient care.

Heyman states:

It has been my experience that most physicians involved in policy making in the health IT field are unrepresentative of people like me. They are either not practicing at all or they practice one day a week in a huge institution or network. They never do their own coding and billing and have a buffer in place when it comes to measures as well. We little people have no buffers, no counters, no billers, and no paramedical people to help with our workload. Most physicians in this country are in small practices, and most patients in this country are cared for by those physicians. So when a policy maker who has never been in our shoes sets requirements for measurements, a red light and siren should go off to remind people to be sure that the measure is so important that it is worth decreasing efficiency and making technology less attractive to the folks who take care of most of our patients.

Unfortunately, this is entirely true, not just in Meaningful Use, but in various facets of healthcare. Although there are many areas where care can be dictated based on robust study of the evidence, we have entered uncharted waters in knowing whether the dictates of Meaningful Use will actually deliver quality care outcomes. Personally, rather than a hodgepodge of measures thrown together in the guise of Meaningful Use, I’d love to see demonstration projects on each of the measures to determine whether they are indeed valid.

We see this kind of evidence in the Quality Measures portion. Many of these are well-researched disease management elements that have been shown to reduce the burden of disease, improve quality of life, and reduce health care costs. I’m all for these types of measures.

What I’m not for, however, is mindless box-clicking such as Dr. Heyman describes when having to “remember to put a check mark in place saying the patient has no problem every time I would have left the problem list blank.” Playing devil’s advocate, of course one could argue that physicians left the problem list blank because they were lazy, or thought a problem unimportant, etc. Instead, however, we’re going to make everyone check a box instead so we can measure it.

As someone who has spent a great deal of her career in process improvement initiatives, I do fully embrace the concept that what gets measured gets managed. In this case though, I fear that all we’re going to manage is to have providers leverage staff to simply check the box so they don’t have to, potentially increasing inaccuracy rather than what was probably intended, which is to make sure patient charts have accurate and complete problem lists.

He also shares his frustration with requiring collection of ethnicity on each patient, with which I heartily agree. A good chunk of patients out there have no idea of the difference between race and ethnicity – frankly, how many healthcare providers can accurately explain it? – and quite a few patients are offended that we’re even asking. This requires someone in the office (often the physician, who hears the patient complaint even after staff has tried to address it) to explain the goals are of gathering the data, wasting precious time that could have been spent on health counseling, taking a detailed history, and undertaking more clinically relevant pursuits that have been shown time and again to improve outcomes.

For many providers, Meaningful Use is too much, too fast. I know that my staff, regardless of technology, prompts, and reminders, can only focus on so many elements at a time (and we were early adopters, so the distraction of the technology itself is long gone.) In a perfect world, we’d like them to be able to spend their time focusing on issues that will really make an impact with an individual patient rather than gathering individually irrelevant data for broad population initiatives. I’d like my staff to spend that explanation time making sure the patient has resources to pay for her medication so she can even take it, rather than worrying about discerning what my patients call “where my people come from.”

Patients want us to be present in the moment – in the exam room with them, focusing on individual issues and getting to know our patients as people. That is increasingly hard to do when providers are being graded on whether those same patients actually do what we ask them to do and also whether we checked the appropriate box to correctly document it. We’re no longer paid for patient rapport, cognitive ability, or compassion. We are, however, paid for playing a game where checkboxes and regulations rule. This is sad.

I close with another great comment from Dr. Heyman:

We cannot fix everything in medicine with Meaningful Use, and we should stop trying to do so. We can fix lots of things with technology and innovation, but let’s stop micromanaging physician practices. Let’s move from Meaningless Documentation Measurement to Meaningful Care! We can be so much more innovative than Meaningful Use.

And from the back pew of my hospital’s chapel, Dr. Jayne says “Amen!”

E-mail Dr. Jayne.