Let's Limit 'Meaningful Use' of EHRs to What Really Works

Under the provisions of the economic stimulus law, physicians and hospitals must make "meaningful use" of a qualified electronic health record in order to qualify for government financial incentives that will be available in 2011. To help define "meaningful use," the National Committee on Vital and Health Statistics, an HHS advisory body, this week held a two-day hearing that included testimony from a number of interested parties, experts, and government leaders. The consensus of physician and industry representatives was that meaningful use should include interoperability, the ability to report standard quality measures, and advanced clinical decision-making.

The ability of EHRs to communicate with one another still has a long way to go, and so does their ability to report quality measures based on clinical data (as opposed to claims data). But the biggest problem is in the area of clinical decision support (CDS). As a new Business Week article points out, there have been several instances of hospitals actually exposing patients to harm by using computerized decision support systems. The investigative piece cites hospitals using systems made by Cerner, Eclipsys, and Epic.

For example, the Geisinger Health System in Danville, Pa., often held up as a health IT success story, had a problem with incompatibility between its Epic EHR and its pharmacy database. As a result, wrong medications were ordered for some patients in the psychiatric unit of its flagship medical center. Geisinger discovered the errors after a few weeks and fixed the flaw at a cost of $2 million.

At Children's National Medical Center in Washington, DC, "doctors and nurses discovered an eightfold increase in dosage errors for high risk medications" in 2006, the article said. "They attributed the trend to a Cerner system installed six months earlier." No patients were harmed, but the hospital had to revert to an ordering system that used paper notes.

The writers also point to the common phenomenon of "alert fatigue," in which clinicians ignore computerized alerts, perhaps because they're tired or they don't believe the alerts are valid. Often, alert fatigue occurs because the software over-reacts to factors that aren't really dangerous. But one also wonders how many drug interactions, for example, are missed because physicians can't find a paper chart and don't know what medications a patient is taking. According to some physicians BNET has spoken to, electronic prescribing has prevented potentially harmful errors.

The Business Week article overstates the case against health IT, partly because it focuses mainly on hospitals, and also because it doesn't cite examples of EHRs improving the quality of care. As for the argument that health IT vendors are lobbying hard for government funds, what else would you expect them to do? But the piece makes some very valid points about clinical decision support.

At a recent conference of HIMSS, the association of health IT professionals, CDS experts admitted that the technology needs much more work. Dr. Blackford Middleton of Partners Healthcare in Boston noted that best-practice guidelines need to be integrated into EMRs or "standard web services" that physicians can use at the point of care. Dr. Dean Sittig, a professor of medicine at the University of Medicine and Dentistry of New Jersey, said that CDS should go beyond alerts and reminders; it needs to be woven into EHR templates, default values, order sets, and other parts of the program. That's all fine--but CDS must also be reliable, so that patients always get the best and safest care.

If we are going to make "meaningful use" the bedrock of health IT planning, we better make sure that it is applied only to well-tested components of current EMRs--along with worthy adjuncts such as electronic registries. Otherwise, we may get both more and less than we bargained for.