Last month, six Republican senators released a document entitled “Reboot: Reexamining the strategies needed to successfully adopt health IT.” The report asserts that the original goal of the $35 billion EHR meaningful use incentive program was to achieve “interoperability,” creating a “secure network in which hospitals and providers can share patient data nationwide.”  The report expresses concerns that the meaningful use incentives and federal HIT policy in general are not achieving this interoperability goal and are instead increasing costs, leading to waste and abuse, threatening patient privacy, and leading to unsustainable IT infrastructure.

Since then, a number of parties have offered written responses, including the American Hospital Association, the Texas Medical Association, a consortium of consumer groups,  a group of EMR vendors and the “Healthcare Innovation Council.”  Both the senators’ document and virtually all of the responses agree with the premise that the health care system needs to be improved, and that improvements to health information technology are a necessary component of any effort to improve the health care system.  Almost all parties also agree that the $18.5 billion spent so far on stimulating EMR roll-out has not yet led to any great improvement in the health care system.  But, different parties express very different views about whether the incentive program as currently designed will eventually lead to such improvements.  And, among those arguing for “rebooting,” there are diverse opinions about what a rebooted program should look like.

On one level, the senators’ report fits into the frustratingly conventional narrative of political polarization, with senators from one pole arguing that the administration from the other pole is doing a bad job.  On another level, it fits into the deeper philosophical differences of opinion regarding the role of government spending and regulation vs. private enterprise in the health care system.  On a third level, the report represents the special interest views of one set of constituents, health care providers, who like receiving government funded incentives, but would prefer the bar to be lowered to earn those rewards.

Likewise, the responses defending the meaningful use program can be viewed as defending the administration’s record, promoting public involvement in health care, and representing the views of another set of constituents, the health care IT vendors, who really like the tsunami of revenue they are receiving as a result of HITECH and who fear that “rebooting” might end up more like “unplugging.”

The most interesting response

A group called the Healthcare Innovation Council released what I consider to be the most interesting of the responses to the senators’ “reboot” document.  This Council was assembled by Anthelio Health, a health care IT outsourcing  company and consultancy that is not among the EMR vendor insiders that are reaping the greatest rewards from HITECH.  The Council includes a few leaders of health care provider organizations and leaders from other health IT and analytics companies not including any major EMR vendors.  Their report is entitled “Let’s Admit the Emperor has No Clothes: It’s Time to Redesign EHRs to Improve Patient Care.” They assert that EHRs have not led to the envisioned improvement in the health care system, and offer their diagnoses:

EHR design issues

• “EHRs, to date, have been fundamentally designed to create electronic versions of paper medical records.”
• “EHRs focus on data collection mostly for regulatory compliance and financial reporting, not to assist physicians, nurses and other clinicians in providing higher quality more efficient patient care. “

EHR implementation issues

•  “EHR implementations are often led as IT projects by teams that do not obtain robust, meaningful, future-focused input/involvement from nurses, physicians, pharmacy and other clinicians who provide patient care. The end result typically is that EHR implementations don’t make life better for EITHER the clinician or the patient.”
• “CMS’ and healthcare providers’ focus has been to ‘just get EHRs up and running‘ in a way that meets CMS’ meaningful use requirements so that they can get meaningful use dollars, without regard to how that affects patient care.”

I see the problem the same way.  But, the tricky part is the remedy.

The Healthcare Innovation Council’s paper first advocates for increased involvement by clinicians (with an emphasis on nurses) in the redesign of EHR technology.  On the surface, this is not really a controversial point.  The Council’s paper reverently referenced Steve Jobs twice in the paper as an innovator and simplifier.  But, it is interesting to note that Jobs was famously against too much end user involvement in the design process, arguing that users don’t have an easy time re-conceptualizing things.  People wouldn’t have asked for an iPod, an iPhone, or an iPad because they had never experienced them before and had established mental models of how to buy music, navigate, take movies, read books, etc.  The problem is on display within the Council’s document.  They write:

• “EHRs are not designed to reflect or facilitate the way in which providers deliver patient care, and thus disrupt, rather than enhance, patient care”
• “Improved focus on EHR design and implementation that starts by mirroring the way care is actually delivered by nurses, doctors and other clinicians.”

They seem to be asking for EMRs that “repave the cow paths,” a problem I’ve discussed in a prior post.  But, the Council at least seems aware of the difference between status quo and real disruptive improvement:

• “This basic design then would move to new, information enhanced processes that not only help clinicians do their jobs easier, but measurably improve patient care safety and quality.”
• “Rethinking, redesigning and re-engineering nurse, physician and clinician workflows to take full advantage of the capabilities of the new (and evolving) EHR tools to result in improved healthcare processes and care experiences.”

In addition to advocating for clinician-led EHR redesign, the Council’s remedy also includes having the federal government require providers to demonstrate “actual patient care improvement and better patient care process” to earn the incentives.  That’s a lovely thought, but imagine how many pages of regulation it would take for the federal government to define specific care processes that it considered to be “better” and methods to document that such care process changes were connected to the EHR technology.  Beware of what you ask for.

The last line of the Council’s paper is, perhaps, the most interesting.  The authors agree with the senators that it is time to “reboot” the meaningful use incentive program before all the money is spent.  Then, almost as a throw-away line, they add:

• “Unless that is done, then we urge Congress to halt CMS’ “meaningful use” EHR program and spend the remainder of the “meaningful use” funds on providing financial incentives for hospitals and other providers that demonstrate “meaningful improvements in patient care” through whatever means they choose, and leave it to the healthcare providers, not our federal government, to choose the most effective means to improve patient care.”

Financial incentives for improvements in patients care is what value-based reimbursement is all about.  The Healthcare Innovation Council is basically saying that if you want effective, real improvement, rather than just superficial “compliance,” you need to pay for value.  Of course, the nation is transitioning to value-based reimbursement.  But that process is going slowly and the percentages of reimbursement that is value-driven has tended to be small.  As I’ve argued before, incentives tied to compliance is the opposite of real improvement, no matter how hard you try to make compliance meaningful.  If so, maybe we really need to consider re-allocating the remaining meaningful use funds to speed up the transition to value-based reimbursement, rather than just rebooting meaningful use.