This blog explores “nudge theory” as it relates to meaningful use. Earlier posts introduced “nudge theory” and looked at implications to state exchanges. In pointing out the nudges I also hope to provide a current overview. (Cited sources are linked)
If you missed the introduction, and wish to further understand the premise of “nudge theory” please visit Introduction. For nudges relative to state exchanges, visit Part I.
Meaningful Use (MU)
According to the U.S. Department of Health and Human Services (HHS), the goal of meaningful use is “to promote the spread of electronic health records [EHRs] to improve health care in the United States.” And benefits of meaningful use were further defined to include “complete and accurate information… better access to information… [and] patient empowerment .”
Given our out-of-control healthcare costs and a growing patient population (silver tsunami), this is a laudable plan.
The HHS, to promote EHR adoption, introduced incentives by the way of stimulus funding to qualified participating physicians to implement EHR systems… and penalties by way of reductions in reimbursement for non-participants.
These participating physicians must be seeing Medicare and/or rural Medicaid patients. Hospital-based physicians are not eligible. Long-term care physicians and facilities aren’t eligible; they are lagging behind in EHR adoption.
Stimulus CMS dollars were available in 2010; eligible physicians had to show six months of meaningful use to qualify for funds. But this is where meaningful use starts to get fuzzy; why no one can define it. CMS guidelines consist of three stages (over five years) to achieving meaningful use. The stages cover (1) data capture and sharing, (2) advance clinical processes, and (3) improved outcomes.
Each stage has its own timeframe (reaching out to 2016) with a criteria-focus-set from which eligible participants get to “pick” their own core objectives. Variances occurred here making it harder to define meaningful use.
If core objectives are different, what is meaningful use? Most healthcare professionals would agree that meaningful use comes down to data exchange and patient engagement. But exchanged how, accessible to whom?
Exchange: Looking back, the push for electronic medical records or EHR adoption created an incubator. More than 500 EHR vendors are now approved by CMS, each with its own proprietary software. Lack of interoperability is putting a strain on EHR adoption; as is inflexible, non-customizable software… high costs, and fear of vendor instability. Still, we need tools to manage patient records, care coordination, and reimbursement. The challenge to physicians is that existing EHR tools focus on supporting reimbursement claims rather than care delivery and physician work flow.
Access: Healthcare providers, care support teams, and billing staff; insurance companies, and billing services; hospital systems, clinical staff, non-clinical support staff, billing departments, and medical records oversight all have access. Touch-points have grown and EHR systems are creating more touch-points (vendors, trainers, storage and retrieval points, etc).
HIPAA (Health Insurance Portability and Accountability Act of 1996) established standards for all touch-points around healthcare information. The goal was to make certain healthcare information is protected while allowing for meaningful flow of information to support care. Rules were set in place dictating access, as well as laws to penalize inappropriate use of or access to patient information, but there were no guidelines set for interoperability.
We are facing major hurdles because interoperatbility was not mandated.With the advancement of technology in healthcare, secure data exchange is a priority. With so many systems touching healthcare databases, debates are forming around who actually owns the health data.
Health insurance exchanges are being created in order to provide insurance options to US citizens. These systems will have to interface technologically. They will have to interface with existing EMR/EHR systems, and with personal health records (PHRs).
EMR/EHR clarification: Doctors and hospitals have traditionally referred to medical data collected for patient care as “medical records” but when health information is exchanged with payor and quality measurement systems they are referred to as electronic health records.
We seem to be creating more silos but meaningful use of exchanged information will have to happen if we are to provide expeditious, non-redundant care to our patient population. Health insurance exchanges being created today will nudge change. Players will not be able to participate in these exchanges without interoperability.
Perhaps the most critical influencer of how healthcare will continue to evolve is the patient. Perhaps their significance has been overlooked, but the big question being asked around healthcare tables today is how to encourage patient engagement. That is the final piece; how to help all of us become active participants in our healthcare management.
As to the notion of a healthcare reform being a “nudge theory” exercise, well it certainly applies to meaningful use. Incentives to promote use were given, limited guidelines set, and we are still figuring things out. Still, I am convinced we will evolve to a better healthcare information system; change comes from a little chaos. Next, patient engagement… perhaps the most important piece.
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Sources: Cited references are provided as links in text. I apologize for deviating from APA formatting.