Curbside Consult with Dr. Jayne 12/17/12

ONC released the 2014 Edition Test Method for EHR Certification on Friday. In case you didn’t have anything to do over the holidays, now you can curl up in front of the fire with some cute and cuddly Test Procedures.

I have to be honest. I still struggle with Meaningful Use. I completely understand the goal. I also understand that there are a number of baby steps that must be taken in order to make data more transparent and transferrable. It’s extremely frustrating as a clinician, however, to have to codify data in ways that are seemingly meaningless.

Take the certification criteria for smoking status, for example. The Test Procedure document includes the approved SNOMED CT concepts “to assist the developers and implementers of EHR technology in the implementation of this requirement.” The concepts are:

• Current every day smoker
• Current some day smoker
• Former smoker
• Never smoker
• Smoker, current status unknown
• Unknown if ever smoked
• Heavy tobacco smoker
• Light tobacco smoker

For a minute, I’m going to take of my informatics hat and put on my average primary care provider hat. Let’s assume the only thing I know about SNOMED is that it’s some kind of coding system that sits under my EHR (if I even know that much, which I might not). Although the coding allows each of these to be uniquely identifiable, I’m not sure any of these (other than “Never smoker”) have specific levels of meaning to the majority of primary care physicians without detailed explanation.

For example, what is the definition of a heavy vs. light tobacco smoker? There are significantly different clinical risks to the former smoker depending on whether they’re a former heavy smoker vs. a former “only when I drink with friends” type of smoker.

There is a clarification that “smoking status includes any form of tobacco that is smoked, but not all tobacco use.” There are different risks to pipe smokers and cigar smokers than to cigarette smokers, but we’re not required to capture that nuance. In the old world, I could write TOB: 2ppd x 20y and 99 percent of clinicians would translate that to “cigarette smoker, two packs per day for twenty years” and could appropriately assess the patient’s risk. Now, to meet Meaningful Use, I’m going to be steered towards selections that don’t have a lot of clinical meaning.

Some vendors who had detailed and granular ways of documenting this information prior to Meaningful Use have kept their ability to gather that useful data and mapped it to the required codes. I can’t help but think that this will cause the data to lose something in translation.

Other vendors who are focused more on certification have added the new fields alongside their old ones. This forces clinicians to document the data twice – once for clinical significance and once for a federal program. Although it meets the letter of the law, it makes for unhappy users and poor design. I know of at least two products out there, however, which function in this way.

ONC works through the paradox of mapping on page 3 of the smoking status document. It gives the sample of a “pack a day” smoker that the Certified EHR maps to “current heavy smoker.” It notes that when the transition of care document is created, the additional text description and any other metadata could be included along with the SNOMED. It continues”

Note that “heavy smoker” is not the only concept that is appropriate here, and we leave the decision regarding which of the eight codes is the most accurate descriptor of clinical intent to the judgment of those implementing the form, template, or other EHR data capture interface.

I’m not sure that makes me feel much better. Unless they have dedicated clinicians working through these design specifications, it leaves us with software developers deciding how to best document clinical intent.

As the document continues, they include language from the 2011 preamble of the Health Information Technology standards document. It specifies the definitions of the various selections:

… we understand that a “current every day smoker” or “current some day smoker” is an individual who has smoked at least 100 cigarettes during his/her lifetime and still regularly smokes every day or periodically, yet consistently; a “former smoker” would be an individual who has smoked at least 100 cigarettes during his/her lifetime but does not currently smoke; and a “never smoker” would be an individual who has not smoked 100 or more cigarettes during his/her lifetime. The other two statuses (smoker, current status unknown; and unknown if ever smoked) would be available if an individual’s smoking status is ambiguous. The status “smoker, current status unknown” would apply to individuals who were known to have smoked at least 100 cigarettes in the past, but their [sic] whether they currently still smoke is unknown. The last status of “unknown if ever smoked” is self-explanatory.

I wonder how many of my primary care peers have read this language and share this definition? It’s been awhile since I was in medical school and residency, but I’m pretty current on my continuing education classes and haven’t seen this emphasized in recent articles about the risks of smoking. What’s magical about 100 cigarettes? Is there solid data that shows a difference in risk once a smoker hits that number? Maybe I need to go back to school.

Continuing on, the document clarifies the cutoff of “heavy vs. light” smoking as being more than 10 or fewer than 10 cigarettes per day, “or an equivalent (but less concretely defined) quantity of cigar or pipe smoke.” What if they smoke exactly 10 cigarettes per day? They don’t meet either definition.

I realize I’m splitting hairs here and some of you may have tuned out by now, but that’s the point. We’ve taken data that had clinical meaning and was easily understandable and turned it into data that is confusing and potentially meaningless. I’m not sure if that’s really taking us forward. The data is only as good as the staff entering it and the likelihood of physicians understanding the concepts (let alone training their staff to understand the concepts) may be low.

Compared to other parts of MU, the documentation of smoking status seems fairly straightforward. That’s not very reassuring considering a program which will continue to become more complex as we move forward. We’re not even to Stage 2 yet and I need a break. As they used to say, smoke ‘em if you got ‘em.

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