Meaningful Use in the ER: Interview with Dr. Whitney Kiebel

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The writing has been on the wall for years and CMS has read it. While the Meaningful Use program may have achieved its goal of widespread EHR adoption, the time has come to focus on performance and patient outcomes.

Andy Slavitt MU TweetWhile the program can be hailed for catalyzing a wave of modernization in the healthcare industry, it can be equally roasted for ignoring EHR usability, letting the role of physicians in providing data entry and compliance get out of control, and delivering attestation requirements with no apparent relevance to the delivery of quality care. American Medical Association President Steven J. Stack, MD argued that, “Most electronic health record systems fail to support efficient and effective clinical work. This has resulted in physicians feeling increasingly demoralized by technology that interferes with their ability to provide first-rate medical care to their patients.”

Cue CMS head honcho Andy Slavitt announcing the death knell for MU at the J.P. Morgan Healthcare Conference January 11th, and later in a tweet that pledged “something better” is on the way, causing some dissatisfied doctors to celebrate and some to shrewdly ponder the corporate greed and regrettable sunk cost of the program thus far.

It is a welcome change for most, but who’s to say what comes along next will be any better? The uncertainty around MU’s replacement has led many to temper their enthusiasm. The College of Healthcare Information Executives (CHIME) is advocating to CMS and congressional committees for ”greater alignment and harmonization of quality measures; creating parity between eligible professionals and eligible hospitals; and removing the pass/fail approach to gaining incentives; reinstating the 90-day reporting period; and ensuring that MU focuses on using IT to transform care, not just reinforce a check-the-box mentality.”

“Most electronic health record systems fail to support efficient and effective clinical work. This has resulted in physicians feeling increasingly demoralized by technology that interferes with their ability to provide first-rate medical care to their patients.”

Echoing the sentiment that it’s high time to move into the phase of making the program live up to it’s Meaningful moniker, Karen DeSalvo, MD, National Coordinator for Health Information Technology affirmed that “this new chapter” of health IT will be “more about knowledge that can come from that data as opposed to thinking about the adoption of platforms themselves.” We know this will involve transitioning to the Medicare Access & CHIP Reauthorization Act’s (MACRA) emphasis on Merit-Based Incentive Payment System (MIPS) and alternative payment models, but as of yet it seems the champagne should remain corked.

While the industry awaits CMS and the government to shed light on future health IT incentive programs, we wanted to hear from a local MD about her impressions of MU, the rapid adoption of EHRs, and their impact on how physicians take care of and interact with patients at her organization.

Dr. Whitney Kiebel, MD, iMU Quantum States an emergency and pediatric physician in her final year of residency at the University of Arizona College of Medicine in Tucson. She was interviewed via email in late February.

HealthTECH: What are your overall feelings on the the impact EHRs have had on your day-to-day work?

Dr. Kiebel: I 100% agree with the comments [from AMA President Stack]. Sometimes [the EHR] reminds me to do things that I otherwise would not…but for the most part, I do not find it useful and it just adds another tedious task to our charting. I spend significantly more time at the computer than I actually do interacting and caring for patients. The EPIC interface is probably the best one that I have worked with and does make it easier (I have used CERNER, Meditech and Sunrise Clinical Manager).Kiebel MD

HealthTECH: While the MU program may have accomplished its primary goal of getting providers to adopt EHRs and begin digitizing patient information, and we can acknowledge there have been challenges, what value have these efforts had to you and the organization? If not now, are you confident that we will see the value of this massive endeavor in the future?

Dr. Kiebel: I do like EHRs. I think it is easy to get carried away with various things that are purely just for data and have no merit in affecting patient care (i.e. MD in room button). We have it set up in our department that we bring computers with us into the room. In order to actually chart efficiently most people do this. I do think that typing does take away from the patient experience and makes it less personal. But there is no way that I could get my charts done in time if I did not do this.

The best thing about EHRs is being able to look at old records. In a busy emergency department, this would be impossible to do without EHRs. This has seriously changed my practice, particularly in patients with chronic issues or who frequently visit. It would be nice if there was a better way to link with other hospitals in the community.

HealthTECH: Part of the announcement of the MU changes included a new focus on the use of API’s to promote innovation. What do you imagine true innovation in Healthcare IT looking like?

Dr. Kiebel: I really like the idea of the APIs. Patient’s need better access to their records. However, sometimes a test will come back abnormal and in the appropriate clinical context it is not something that I would be concerned about. It is hard to communicate that with patients and to prevent unnecessary worry. So though I like the idea, it may not be the most productive in some situations.

I think promoting communication after a visit is very helpful particularly in the primary care setting.  As far as a busy ER, probably not as much so since we do not have a longstanding relationship with our patients (most of the time). It is much easier to type a quick text or email to a patient, than to try to get in contact via snail mail or phone.

It would be amazing if healthcare IT could come up with a way to link all EHRs so that we could access other hospital’s data.  I have so many patients that come in and say, “I don’t know my list of medications, don’t you have it on file?” It would help us eliminate unnecessary admissions and workups.  I have had patients come in that have had extensive workups in other cities but I have been unable to access these records, and as a result end up ordering the same workup for the patient here because legally I do not have any documentation of prior workups.

“It would be amazing if healthcare IT could come up with a way to link all EHRs so that we could access other hospital’s data.  I have so many patients that come in and say, ‘I don’t know my list of medications, don’t you have it on file?'”

HealthTECH: What are your feelings going forward with Stage 3 attestation, MIPS, and alternative payment models? Incentivizing good quality care is obviously the goal, but developing metrics to measure that quality sounds tricky.

Dr. Kiebel: I do not quite understand the impact that this will have and it sounds like it is really tricky. I do agree that incentivizing good care is necessary, but I do not know if these models really assess that. They are trying to objectify something that really can’t be objectified. To be penalized financially because you are not clicking buttons on a computer seems like the wrong way to grade physician care and doesn’t seem like an appropriate model of determining physician reimbursement.

Many places have hired scribes to ensure efficient and effective charting. It is kind of crazy that you have to hire somebody to chart for you, but most places are moving to this.

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