Room for improvement, but MU has done good

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BOSTON—Albany Medical Center has experienced huge changes due to Meaningful Use (MU), said Patricia Hale, MD, PhD, the organization’s associate medical director of informatics, speaking at the 2014 AMDIS Fall Symposium.

“There’s a dark and dirty side to this kind of work.” Although the MU money moved the institution from read-only EMRs to a position where they’re just starting to integrate with other organizations, the time crunch required a lot of change in a short period of time.

For example, there are now limitations in the EHR and Albany struggles with partial implementation of a patient portal, she said. The schedule made it difficult to figure out how to make up for the vendors who didn’t meet all the MU the hospital had. Critical resources were pulled from other projects to meet MU deadlines and quality projects were put on hold.

Unfortunately, components were added to the EHR just to meet MU requirements, Hale said, “and we know we have to replace them because they aren’t what we want at the end of the day.” The hospital now faces software updates more frequently than ever before which puts real stress on the IT department.

Hale went through a typical patient admission via the emergency department to cover the pros and cons MU has brought to their system. The first challenge when a patient comes into the ED is medical history. What information is gathered from outside sources and who is responsible for collecting the information.

One of her big concerns, Hale said, is that “more information can be more chaos if we don’t have a way to deal with it. I think this is a huge task moving forward and something we should already be concerned about.” While Albany can access information from other sources, it’s not in a usable form.

For admitted patients, hospitals are required to have a problem list. Albany never had that so had to create the process in six months. “We recruited ED physicians to help start the process by getting all patients admitted with at least one diagnosis from the problem list.” They started off with a dropdown list. They also learned that vendors all do some sort of modification of SNOMED in their software so the available terminology might be lacking. Mismatching language can result in adding more inaccuracies to the record. “We can sometimes find 16 or 17 problems in the record that haven’t been resolved. We’re accumulating problems without any ability to manage them. No one thinks it’s their responsibility.”

When Albany implemented CPOE, it was a rapid process and, “as a result, we were not able to everything we wanted to with order sets to make them as optimal as possible,” said Hale. They had physician teams work on the order sets and established a uniformed design but will have to continually go back and optimize them. “I think a lot of organizations will have this optimization challenge going forward.”

Albany had numerous quality projects scattered around the hospital before MU, said Hale. “Trying to pull them together and tie them into MU is extremely difficult.” The hospital chose not to do quality measure reporting for Stage 2 because of the challenges of reporting, she said. Billing for inpatient and professional fees are all done slightly differently and work off of difference databases. “Trying to align these is a huge issue. It’s one of those things where the solutions aren’t really there yet.”

Transitions of care have been challenging as well, Hale said, because addresses are inaccurate when considering individual clinicians, organizations and multiple offices.

“We’ve had trouble just sending to our own faculty practice.” The hospital has interpreted MU rules as meaning that all lab data must be included in those summaries, she said. Providers begged them to stop sending all that data. “Content is very difficult.” They sent all the data during the clinical period for which they were reporting and then stopped and will only do it again for reporting purposes. “It’s not a consumable piece of information for any office to use.”

For the time being, Albany is sending transitions of care to holding areas where they are not consumed into the record but accepted by the receiving office. That meets MU but it’s not ideal, she acknowledged.

“There are big pluses in what MU has brought to us,” Hale said. “I’m hoping that for the next phase, they will say ‘now you have the tools, let’s use them the best way we can and move things forward.’”

“Doctors as a whole are very critical of Meaningful Use,” said Peter Basch, MD, medical director of ambulatory EHR and health IT policy at MedStar Health in Columbia, Md.

But, he said, the program forced healthcare for the first time to focus on giving something to the patient. The amount of information patients retain when they are sick and scared is miniscule. The MU visit summary “has resulted in a consistent, timely creation of something for patients after visits and procedures. We’re putting instructions down in a way that patients can read it and ask questions. That’s very useful.”

Basch said he is concerned about granularity of medication lists. The way it reads now it’s overly specific, he said, which can be a waste of time. “We have limited time with patients. What is the benefit of that granularity?”

The visit summary is one thing that needs works, he said. “It over-specifies what we have to do.” However, he acknowledged that “health IT shines a bright light and helps us see what we need to do.”

That includes giving patients clear instructions. Basch said there are doctors who never gave out instructions before who now are focused on making sure they are clear enough.

Clinicians complain a lot about summaries of care, he said, but “they are based on real need. Before, specialists would see referred patients without knowing the reason for the visit which is a waste of time and money. However, healthcare has to make sure there aren’t “buried headlines” and “a lot of distraction” in the summaries.

Overall, “we are creating value for our patients,” Basch said. “It’s important to remember that MU did do a lot of good. It certainly needs to be improved and tweaked.”