When the code should say ‘codeine’
Even with all of the burdens small practices have to overcome to meet meaningful use standards, Cathy Costello, a program manager for CliniSync, an Ohio-based regional extension center, said more could be done by all parties involved to fix interoperability problems.
“Interoperability requires ‘two to tango,'” Costello wrote in an email to FedScoop. “You can’t send [an email] to yourself and meet the interoperability standards. Although the vendors may provide the technical underpinnings for interoperability, I have yet to meet a vendor who goes out into the community and knocks on doors to make sure the receiving party is set up to accept a transmission of a transition of care document.”
Dr. Jon White with the Department of Health and Human Services’ Agency for Health Research and Quality said vendors should apply more effort in making sure providers are fully satisfied with their products.
“In general, making sure the user experience is the best it can possibly be may not have been the highest priority for the vendors,” White said.
While White said there is “a lot of ground to cover” when it comes to interoperability, he has talked with many doctors or health care systems that love how far EHRs have come over the past decade.
“Some of the most ardent skeptics have said to me that the system we have now is in many ways better than the system we had,” White said. “In a lot of ways, we do have interoperability now. I think what people are struggling with is that the interoperability we have now doesn’t match the ideal of what we all conceive it to be. My gold standard is not going to be the same as other people’s gold standard.”
There have been recent studies that disagree with White’s sentiments on interoperability. A study published in late June in the Journal of the American Medical Informatics Association found that EHR systems that have been certified for meaningful use aren’t always interoperable with other EHR systems.
The study found common errors in data that were fed into Consolidated Clinical Document Architecture (C-CDA) documents, which allow data to move through EHR systems. Some of the errors included incorrect dosage data or codes used in systems that confused penicillin for codeine.
“Data heterogeneity or omissions may impose a minimal burden in cases where humans or computers can normalize or supplement information from other sources,” the report stated. “In other cases, a missing or erroneous code could disrupt vital care activities, such as automated surveillance for drug-allergy interactions.”
In another study published in June, the RAND Corporation found that meaningful use requirements for interoperability were “watered down” and promoted adoption of current technology instead of promoting emerging products.
“By subsidizing ‘where the industry is’ rather than where it needed to go, HHS rule-makers allowed hospitals and health care providers to use billions in federal subsidies to purchase EHRs that did not have the level of connectivity envisioned by the authors of the HITECH act,” the report stated.
Somplasky and Byrnes both said they have seen the “watered down” scenario play out in their own experiences.
“There are areas where [EHR vendors] squeak by on the certification and there are other areas where they have done very well,” Byrnes said.
“There is a certification process, but within that process, you had some real dogs,” Somplasky said. “We would just sit there and wonder ‘How did [this EHR vendor] ever make it through the test?”
White said one area where “there is a lot more room to work” is figuring out a post-implementation testing phase so health care providers can learn all the ins and outs of the EHR system they just purchased.
“The value of an EHR is it should be able to say ‘Wait a minute, did you really mean to do that?’,” White said. “What you find is systems have a capability, but when they are implemented in a given hospital, there’s traces about what alerts you turn on and who gets that alert. What you find is as implemented, those tools may catch the things you expect them to [and] they may not.”
Yet even with flaws, White said doctors should be able to recognize basic errors that come from EHR systems.
“There’s a higher level of accountability,” he said. “A doctor should know not to subscribe 10 times the right amount of morphine for his patient.”
Even with a system that is working properly, Schierer said EHRs often take away from the amount of time doctors are engaging with patients.
“The reason doctors are not happy with meaningful use is, if you back up the clock 5-10 years ago when most physicians weren’t using [EHRs], we were all still being paid on volume,” he said. “Now, if I throw in [EHRs], we’re trying to move to a value- and quality-based system, but yet remunerated primarily on the number of patients I see per day. So now what you’ve done is you’ve made [doctors] use electronic medical records, you’re making [doctors] add medications and allergies in a structured fashion. Before, I would just check off ‘chest pain’ on a paper bill and anything I couldn’t find, I would handwrite it and my [staff] would find the code. Now the physicians have to do that, and they don’t have more time to take care of the patients, either.”
