Meaningful Use of Health Information Technology Is Managing Information

Abstract

PHYSICIANS ENCOUNTERING A NEW TECHNOLOGY SUCH as electronic health records (EHRs) typically use it to solve the same problems they were trying to address with older technologies. It takes time to determine that the new technology creates entirely new possibilities for practice. For instance, when the electrocardiogram was first invented, it was thought to be a better version of an older technology, the Mackenzie polygraph. The Mackenzie instrument, which made a simultaneous visible record of mechanical events (radial pulse, jugular venous pulse) in the cardiac cycle, was a powerful tool in unlocking the problem of cardiac arrhythmia. Initially, the electrocardiogram was considered simply a “better polygraph” and was used only to understand arrhythmias. Because the T wave and ST segment do not have mechanical equivalents, early electrocardiographers ignored them, overlooking tracing changes now considered classic for acute myocardial infarction. Similarly—but perhaps not surprisingly—physicians today often consider the EHR to be simply a better version of the paper chart. The old problem many physicians are trying to solve with an EHR is the efficient generation of a progress note—a document used to justify payment in a fee-for-service system, in which an office visit is the unit of value. This could explain the incomplete adoption of EHRs documented in many studies. For instance, in a 2005 survey, 16% of physicians using an EHR with the capacity to electronically generate prescriptions were still writing prescriptions by hand. In a 2008 survey that defined comprehensive use as using 4 domains of electronic capabilities (recording patient health information and data, order entry, results management, and decision support), only 4% of physicians reported comprehensively using all 4 domains in their practices, and 13% reported only “basic use,” ie, using portions of 3 domains. Perhaps the gap between potential and actual use results from physicians focusing on the word-processing capacity of EHRs, the only capacity needed if the goal is to produce progress notes documenting visits. One study of the financial implications of EHR adoption in small medical practices found that 51% of the financial return came from more aggressive fee-for-service coding and more frequent use of higher-level primary care billing codes, both supported by more comprehensive documentation. If the goal is to justify billing codes to an auditor, word processing is all that is needed. However, primary care practice poses a different problem: managing the massive amount of information received about patients every day and using it quickly, efficiently, and safely to meet patients’ needs. Word processing does not help do that. An analysis of the work in our primary care office revealed that, on average, there were 18.1 office visits per physician per day. In addition to visits, however, 12.1 prescriptions were refilled, 31.5 laboratory panels or imaging reports were reviewed, and 23.7 phone calls were processed. Each of these activities demands ready access to information. When reviewing a cholesterol test result, physicians need to know if the patient has diabetes, when the last cholesterol reading was obtained and what the level was, what medications the patient is currently taking, and perhaps the patient’s most recent blood pressure. If physicians understood their work to be responding safely and efficiently to these requests—none of which generate revenue in a primary care office—they would make very different use of health information technology. Many physicians are pleased to have laboratory results scanned into the EHR; the resulting PDF document is at least never lost and is readily accessible to the physician from any computer. Although these are major advances over a paper filing system, none of the information in that document can be manipulated by the EHR, because these unstructured data are retrievable only in a cumbersome fashion. They cannot be graphed or trended, nor can they be used to generate reports (eg, all patients with hemoglobin A1C levels 9%) unless entered into the EHR as structured data. It is imperative that physicians understand and start to use this capacity of EHRs, even though it is not immediately rewarding to do so in the current environment. Our office has been storing and recording all information relevant to the care of patients in an EHR since July 2004, assuming that all information stored electronically could be easily searched and retrieved electronically. That assumption proved incorrect; the current technology supporting EHRs simply does not work that way. For instance,