Finding a Personal Meaning in Meaningful Use

At the Chicago Health Information Technology Regional Extension Center Exit Disclaimer (CHITREC) we’ve had many discussions about what Meaningful Use means. We’ve discussed core sets, menu sets, quality measurements, numerators, denominators, eligibility thresholds, attestation, electronic health record (EHR) certification and reporting tools. On the surface, Meaningful Use looks to be a very complicated thing. Why else would we need 62 Regional Extension Centers, a national outreach program, and a small army of talented clinical and technical people across the country to help our health care providers achieve it?

Often when we’re having these discussions, it seems like the real goals of the Meaningful Use measures get lost in the technical details. But in the end, it’s not about getting health care providers to buy software, jump through technical hoops, and change their practices to meet a set of metrics; it’s about using current technology to improve the quality, safety, and efficiency of health care and to reduce health disparities for all people in the United States.

I believe that often the best way to understand how a series of objectives can lead to a greater goal is to look at those objectives in the context of a “real life” experience. To explain why Meaningful Use is important to me and why I think it’s important to people all over the country, I’d like to share a personal family story of a significant health care experience.

Three years ago, my father passed out while riding his bike. He was in good shape and good health, but with a personal history of hypertension and heart murmur and a family history of heart disease, he decided to make a trip to the ER to get checked out. By the end of the day, it was clear that the time had finally come for the aortic valve replacement he and his cardiologist had talked about in the past. After some additional consultation with his cardiologist and cardiothoracic surgeon the decision was made to replace the valve and perform cardiac bypass surgery before the end of the week.

The surgery went extremely well, and my dad was released from the hospital the following week to recover at home with nursing assistance. People who undergo valve replacement must take anticoagulants such as warfarin to prevent blood clotting while the healing process occurs. Anticoagulant therapy requires that patients be tested regularly to determine how their clotting system is functioning. Too little drug increases the risk of blood clots, too much and the patient is at risk for internal bleeding due to poor clotting function. The main responsibility of his home care nurse would be to ensure that the testing occurred on a regular basis and to make sure that he was following his surgeon’s orders with regard to the correct dosage of warfarin.

During the Christmas holidays, my father’s regular home care nurse was unavailable. A new substitute nurse came to check on him, but she forgot to draw blood for the coagulation test. When his regular nurse returned a week later, she noticed the error and drew blood for the test. By this time, his clotting function was so low that his doctor ordered complete suspension of his warfarin usage.

Two days later, my father was admitted to the ER feeling lightheaded and dizzy. Shortly after, he was scheduled for emergency surgery. His normal clotting function had been reduced significantly enough and long enough that his vascular system had no way to heal itself from the wear and tear that comes from normal use and activity, resulting in significant internal bleeding and a ruptured spleen.

My dad was lucky. He went to the ER in the hospital where he had had his valve surgery and with his existing records and my mom’s information, the medical staff quickly identified the problem and were able to start the process to correct it. By the evening, my dad had had his spleen removed, had gone through seven units of blood, and had to spend more time in the hospital. He was stable, and he recovered well, but it certainly wasn’t the recovery experience that any of his health care providers wanted him to have.

It’s easy to blame his substitute nurse in this situation, but her mistake was a simple one. She got distracted and didn’t have the kind of tools that would remind her to draw blood for the coagulation test. In many ways, her mistake was no different than if I left the office and forgot to answer an urgent email because I got called away from my desk by something else. It’s also the kind of mistake that could have been easily avoided with the use of an EHR system that was being used effectively.

What Meaningful Use measures would have improved the chances that my father would have had a more positive outcome while being treated with an anti-coagulant?

Core Set:

  • Computerized Physician Order Entry (CPOE). CPOE involves health care providers using the EHR system to document all medical orders (medications, consultations, lab tests, etc.). In my dad’s case, Meaningful Use of CPOE would have resulted in a record of orders for both the anticoagulant and regular coagulation testing and would have ensured that my father’s health care providers inside and outside the hospital were aware that the test needed to be performed.
  • Maintain an Up-To-Date Problem List. An up-to-date problem list ensures that any health care provider working with a patient has the best possible information with which to make decisions about that patient’s care. If the temporary nurse had been able to review his problem list, it would have helped her prioritize her assistance.
  • Maintain an Active Medication List. An up-to-date medication list ensures that any health care provider working with a patient is aware of most or all the medications that a patient is being treated with, and allows the EHR system to make the health care provider aware of any CDS, allergies, or drug-drug interactions. This single measure would likely have had the most impact on my father’s outcome. If my father’s temporary home care nurse had started his visit by reviewing my father’s active list of medications, she likely would have been reminded that he was on anti-coagulation therapy and needed regular testing for clotting function.
  • Implementation of Clinical Decision Support Rules. Patients receiving anticoagulants have a relatively simple testing and management protocol. Clinical decision support rules could have been implemented to remind my father’s health care providers of the need to perform regular testing for coagulation when his medication list was reviewed.

Menu Set

  • Incorporate Clinical Lab Results into EHR as Structured Data and Generate Lists of Patients by Condition. Incorporation of lab results into an EHR, either manually or electronically, ensures that lab data is easily available to all providers supporting a patient’s care and also makes it easier for providers to identify missing results. With all lab test results recorded in an EHR system, my father’s surgeon could have easily reviewed all his patients on warfarin for their recent lab results and determined that my dad had not been tested (or the result had not been returned) and make sure that he didn’t go two weeks without an essential test performed.
  • Medicine Reconciliation at Relevant Encounters and Each Transition of Care and Provision of Summary Care Records. Our current health care system often requires that patients see many different providers or receive their care in a series of health care venues. Medicine reconciliation at care transitions, supplemented by summary care records, ensures that each new set of providers is aware of the patient’s major concerns. In my father’s case, reviewing his medication and previous care records when he transitioned to home care nursing support as well as when there was a nursing assistance transition would have helped to guarantee that the nursing staff was aware of his anti-coagulation medication and his need for monitoring.

Of the 15 Core and 10 Menu Set Meaningful Use Measures, at least eight of them could have had a significant impact on my dad’s experience. There is no guarantee that a mistake would not have been made, but in a well-integrated system where data could be exchanged between trained health care providers, Meaningful Use of an EHR would have meant that there would have been a significantly higher number of opportunities for my father’s health care professionals to have caught the problem before it escalated to emergency surgery and a potentially fatal outcome for a patient who was well on his way to recovery from a successful procedure.

One Comment

  1. Rick Rutherford says:

    Dr. Walunas,
    Thank you for sharing this frightening experience. I happen to agree with you that with the proper amount of training and support, health care providers can and will eventually improve the accurate and efficient exchange of patient information that can save lives.
    I must say that I see a bit of irony in your post. You work for a REC and yet all of the health care providers who you mentioned in your post were specialists. Perhaps yours is the exception to the rule, but one of my frustrations as an employee of a specialty society is that specialists are generally not eligible for assistance from RECs. The services are rendered only to primary care physicians.
    In point of fact, the entire design of Meaningful Use is primarily oriented toward primary care physicians. Many of the menu measures and the quality measures in the MU sets do not apply to specialty practice. Although we are trying to select measures that can by used and train our members to apply them, it is a struggle and many are frustrated that there is not more help.
    Combine that with the fact that ONC and CMS are going much too fast toward increasing the requirements under Stage 2 while remaining completely blind about provider performance under Stage 1 and you have a program with far more gaps than most are willing to admit. It is going to be a long, hard climb to the lofty ambition you describe in your post.
    Rick Rutherford
    Director – Practice Management
    American Urological Association

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