Sunday, February 27, 2011

Liquid Vapor

For the uninitiated, every year HIMSS runs this big huge trade show for EHR and HIT vendors, which is to the HIT industry what Oscar night is to Hollywood. No, HIMSS does not award any prizes or trophies, but it occasions the same breath taking congregation of all industry glitterati in one place, complete with clever little parties and big extravagant shows. There were well over 30,000 people at this year’s HIMSS11 conference, and although I wasn’t one of them, I made sure to follow the events through the steady Twitter stream and many excellent blogs, reports and interviews, because what happens at HIMSS is good indication for what the HIT industry is doing and where it is going. So to summarize all the excitement, the established HIT folks are doing Meaningful Use, which has become yesterday’s news, with HIE being the next project on the books. Everything is being pushed to tablets and the cutting edge innovations are all about a myriad of small Mobile Health (mHealth) applications. Analytics and business intelligence is looming large on a horizon filled with provider consolidation, capitation and value-based medicine.

On the surface, this seems a very logical succession of events. Meaningful Use is collecting data, HIE will make it liquid and, as predicted, 1000 flowers of innovative mobile applications will eventually be blooming to bring the liquid data to consumers and innovators who will slice and dice it to provide us all with unimaginable medical utility. However, in the excitement of anticipation on those balmy Florida nights, it is easy to overlook the fact that this entire chain of events is based on one assumption: somewhere, somehow, someone will have to enter data into the system, consistently, accurately and in minute detail. For free. Is there a problem here?

Well, it depends on who you ask. The Meaningful Use regulators, encouraged by the stated intentions of many physicians and hospitals to seek Meaningful Use incentives, are probably assuming that data will be dutifully entered into HIT systems. HIT vendors seem even more certain in their assumption that data will accumulate in their systems, since very few, if any, are doing anything about data entry user interfaces. The same forms and templates sold four, five years ago remain unchanged in the Meaningful Use certified, and iPad enabled EHR versions of today. If you ask physicians and nurses, they will invariably tell you that they resent being turned into “data entry” clerks. And, yes, unlike other industries where computerization of records seemed to have worked wonders, in health care data entry must be done by the scarcest and most expensive resource in the system. Some of those expensive resources decided to do what highly paid executives have done decades ago: hire a stenographer, or in health care parlance, a scribe; interesting idea, but a partial solution at best, and a new source of errors and inaccuracy, at worst. So, how is it that 41% of physicians and 81% of hospitals believe that they can achieve Meaningful Use, which comes with rather prescriptive data collection requirements?

One answer would be that doctors and nurses everywhere are just fine with clicking on as many boxes as needed to qualify for government incentive funds. Clicking 4 Dollars may turn out to be a successful strategy. Another possibility would be that data collection requirements embedded in Meaningful Use are not so obvious to the naked eye. The place to look is the long list of Clinical Quality Measures. For example, a simple measure such as Adult Weight Screening and Follow-Up (NQF 0421), has the following description: “Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a follow-up plan is documented.” Sounds simple; the nurse weights everybody anyway, and the EHR calculates BMI on the fly, so no problems here. Or are there?

What is the meaning of “a follow-up plan is documented”? Does it mean that you type into the Plan section something like: “recommend 30 minutes walks every day and low fat diet”? Eh, not good enough. First the EHR needs structured data fields to perform calculations and your free text is unusable. Second, this is not a follow-up plan. A follow up plan would involve gastric surgery, referral to dietician, referral to exercise classes or at the very least a V65.3 added to a visit. All the sanctioned CPTs for these activities are provided by NQF (not sure how they end up in your chart though). Just a few more clicks, but we’re not done yet. Like most measures, this one has exclusion criteria, i.e. patients for whom you need not document a follow-up plan. So if you don’t document one, you must specify the reason. Did the patient refuse to discuss such plan, or was there a medical reason not to have a plan, or perhaps the patient suffers from a terminal illness? Need a couple more clicks here to complete this one measure. Does your certified EHR have all those boxes for you to click on?

This was one of the simpler quality measures. If you are interested in hospitals, you may want to look at this CSC report which uses VTE prophylaxis as an example of the mind numbing complexity of data elements required for accurate reporting. As far as Meaningful Use is concerned, if you don’t collect all data elements and your quality measures numbers are less than stellar, there is no harm done. The incentives are not dependent on perceived quality. However, if you’re a physician, maybe not today, maybe not tomorrow, but soon, your paycheck will be dependent on little else. And whether you are an EHR vendor, an HIE vendor, a data analytics middleman or a brand new mHealth vendor, your financial success will be inextricably tied to the amount and accuracy of data entered by clinicians at the point of care. You cannot make liquid that which does not exist.

Solutions? We could continue to apply pressure to practicing clinicians in the hope that the vapors will condense into droplets of liquid data. We could also look for objective liquid data somewhere else, but for some reason I am starting to think that those who want data, are more interested in patient and physician generated data, perhaps because of its inherent richness of intimate details. We could also create EHRs which will allow one-click documentation-by-exception of “normal” quality measure elements, similar to what we did for CMS reimbursement required data elements, and with similar results, i.e. 12 pages of irrelevant visit notes (Bingo!!). Or we could look for true innovation in human computer interaction which will make data collection a transparent byproduct of the practice of medicine. Until then, all the Internet pipes and all the tagged and untagged content flowing through them and all the master patient repositories and all massive provider directories will provide only incrementally better clinical utility than electronic faxing.

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