Meaningful Use Rant 2: Hospital Growth Charts

So this is the second in a series of rants regarding some of the more silly aspects of the Meaningful Use Stage 1 Final Rule. Let’s visit core obective 7 for hospitals (pg 257 Fed Reg):

(7)(i) Objective. Record and chart changes in the following vital signs:
(A) Height.
(B) Weight.
(C) Blood pressure.
(D) Calculate and display body mass index (BMI).
(E) Plot and display growth charts for children 2–20 years, including BMI.

The writers of the Meaningful Use rules were on a good roll there. A through D are totally reasonable. I believe every EHR should capture these things and hospital should be document these vital signs for most inpatient stays.

My best friend’s Dad ran a manufacturing plant. I remember him saying that the way to find the optimal setting on a piece of equipment is to turn the dial until it breaks, then go back one setting. I kind of feel that is what happened with this objective. They should have stopped at (D). Growth charts are great, every pediatric practice should maintain one for each child, and in this day and age they should be computerized. But why would a growth chart be a requirement for a hospital stay? Does that make any sense? I have spoken to a few pediatricians and none of them have stated that there is a medical need for a growth chart in the hospital stay.

This looks like a sloppy cut and paste from the Eligible Provider Objectives to the hospital objectives without thinking through the different environments.

Meaningful Use Rant: Quality Measures

I am writing this post, with the intent on writing a series of rants about the Meaningful Use objectives that must be met in order to secure the EHR Incentives made available by the economic stimulus bill.

Let’s start with the Meaningful Use Quality Measures. I believe this is a huge missed opportunity. We will accomplish them using the same tired back-end abstracting approach that we have always used.

I believe the quality measures will fail to be a tool for caregivers to monitor safety and quality; nor will they create a means by which payors, government or consumers can compare quality.

All of the report specifications are written using SNOMED codes and we do not use that medical nomenclature today. In fact, virtually nobody uses SNOMED. Why not write the quality measures using medical descriptions?

But, the real kicker is that everyone is rushing to measure something without talking about the clinical processes and the appropriate place and way to capture the data in real-time. If we want to be able to have good comparisons, we need to have comparable clinical processes.

Each measure requires thousands of hours of work to design the right clinical workflow and IT processes. But, instead of having objectives that define best practice for managing care and capturing data in real time, we jump straight to measurement. We skipped the most important step.

Simple example: 8 of the 15 hospital EHR Incentive quality measures deal with stroke. At what point do we know that a patient is a stroke patient? Is it when a stroke nurse completes a stroke assessment? Is it when the radiologists reads the brain scan? Is it when the attending physician reviews the CT interpretation and makes the diagnosis and instructs the nurse to begin a plan of care?

Assuming one of these is correct, then a hospital’s EHR would need:

  • a codified stroke assessment form;
  • the ability for the record representing the CT scan of the brain to be flagged by the radiologist (or rad tech) as indicating stroke; and/or
  • the the creation of a stroke plan of care.

There are NO meaningful Use objectives for any of this. Are hospitals using EHRs to monitor stroke in real-time and take corrective action when proper care is not given? Almost none. Instead, a human being will read the hand-written notes and dictated physician reports then key ICD-9 codes into the EHR. Those will then be translated into SNOMED codes to populate reports.

All of this will take place long after the patient has left the hospital.