Meaningful Use Regulations, CMS, HRSA FQHCs and the Stalled Push to Electronic Medical Records (EMRs)

According to Mother Jones, the United States has spent billions on electronic medical records (EMRs)* and we’ve got little to show for it. Digitizing healthcare records was supposed to save time, money, and lives. It hasn’t. That news resonates with us because we’ve written dozens of proposals, mostly for Health Resources and Services Administration (HRSA) and Centers for Medicare & Medicaid Services (CMS) RFPs that either explicitly or implicitly require a discussion of our clients’ use of EMR systems. These clients are usually hospitals, Federally Qualified Health Centers (FQHCs) or other primary care providers. From them we’ve heard numerous heard off-the-record stories about the fiascos that ensued for providers that have implemented EMRs. For example, we worked for a hospital in Southern California that interfaced with a much larger, nationally known hospital that attempted to implement a comprehensive EMR system. The large, famous hospital eventually scrapped a $30 million EMR system because the doctors simply refused to use it.

There seems to be no good solution to the EMR problem. EMRs have been touted for at least the last 15 years as a tech-based way of improving patient outcomes, while reducing healthcare costs or at least bending the cost curve downward (as health policy wonks like to say). EMRs got a got big push with huge amounts of EMR funding included in the 2009 “Stimulus Bill.” The advent of the Affordable Care Act (“ACA,” or, colloquially, “ObamaCare”) escalated the EMR drive. Various Federal and state agencies advocated and then effectively mandated EMRs.

But this well-meaning concept has at best moved sideways. HealthIT.gov promulgates the wonderfully bureaucratically named “Meaningful Use” regulations, which use a combination of incentives (e.g., higher Medicare/Medicaid reimbursements) and threats. The carrots are offered and the threats enforced primarily by CMS. Everyone is supposed to get to Stage 1 of Meaningful Use (data capturing and sharing) on a supposedly smooth trajectory to Stage 3 (improved outcomes). Stage 3 turns out to be like the intergalactic instantaneous travel through spacetime. We’ve yet to find an hospital, FQHC or other client that has reached Stage 3. Most are stuck at Stage 1, with a few bravely claiming Stage 2. We’ve never seen a client hit Stage 3, though they may be out there, perhaps in a galaxy far far away.

The problem is that EMRs are trying to map the extraordinary complexities of the real world into software. The complexity can be seen in the new International Classification of Diseases, ICD-10 Codes, published by our old friend CMS. ICD-10 codes are used by medical providers and billers to track patients and payments, based on the code or codes of the patient’s particular situation. When we talk to FQHCs, they invariably say that coding errors are among their major problems. ICD-10 has an astounding 68,000 individual codes, compared to only 14,000 codes in the previous ICD-9. In recent years, humans have invented or discovered an enormous number of new ways to get hurt. No one can remember more than a few hundred of these mysterious codes, which are easy to mistype into an EHR and/or be misunderstood by harried doctors and mid-level practitioners. The complexity of the codes, combined with human diversity and frailty, inherently generates huge numbers of mistakes.

Folks with too much time on their hands have published various funny ICD-10-CM codes. Some choice ones (we are not making these up) include: “V97.33XD: Sucked into jet engine, subsequent encounter;” Y92.146: “Swimming-pool of prison as the place of occurrence of the external cause” (how many prisons have swimming pools?); and my personal favorite, “R46.1: Bizarre personal appearance.” You can tweet your favorite bizarre ICD-10 codes to @healthcaredive.

Ask your doctor about their EMR system and you’ll likely here a lot of invective. I live with a doctor and so have heard the horror stories from her and her colleagues. Isaac’s primary care physician (PCP) hates EMRs but is more or less forced to use eClincalWorks, an EMR system that is also popular with our FQHC clients. Epic is another popular one. Still, however you feel about whether EMRs is efficacious or horrible or brilliant or whatever, pretty much every healthcare-related proposal has to mention EMRs, statistics, and tracking. That could be as minor as a project that works on childhood obesity or as major as a hospital chain implementing some new facet of EMRs.

Anyway, EMRs are a specialized case of a more general problem described in “Why Software Fails: We waste billions of dollars each year on entirely preventable mistakes.” EMRs, like other forms of software, have numerous moving parts and numerous human users. Anyone working in or around EMRs needs to read “Why Software Fails.” At Seliger + Associates, we expect to keep writing about EMRs for FQHCs and similar clients for years if not decades to come. In the real world, doing EHRs right is simply a Hard Problem—so hard that it deserves capital letters. EMRs are almost impossible to do “right” and yet have to be done right. They’re so hard that we don’t have a solution. “Why Software Fails” explains why a solution may not exist, no matter how badly HRSA or CMS wants one. As the Soviet Union discovered, mandates from above, no matter how strong, do not automatically translate into fixing problems from below.

* EMRs are alternatively referred to as Electronic Health Records (EHRs), particularly in HRSA and CMS RFPs. In ones types “EHR” into Word, or any other word processor, and the autocorrect feature will change it to “HER.” This in annoying, but does result in some unintentionally funny typos. When finished with proposal draft involving EHRs, always do a find and replace for “HER”.

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