Aligning quality incentive measures with physician wellness: When “Meaningful Use” leads to less meaning in a physician’s practice
By Ami Bhatt, MD, FACC
July 5, 2018
Lately, I have been struck by how often the phrases physician burnout and meaningful use are used in any given day, leading both to suffer the same fate: neither one is well defined. While speaking with colleagues across the country, I’ve asked the question, “What does meaningful use mean to you?” The answers I’ve received vary from expletives, to “waste of time,” “hoop to jump through,” and “garbage in, garbage out.” Those in leadership or quality improvement positions have a different insight: “My physicians call any task asked of them ‘meaningful use’,” or “The institution has many governing bodies, each with their own expectations, but they all call their needs ‘meaningful use’ which frustrates my physicians.” The logistics of meaningful use in the electronic health record (EHR) are also often noted: “I forget more than I remember it, but now there are prompts,” and “The extra 45 seconds per note adds up with a busy clinic.”
What is Meaningful Use?
The original 2009 American Reinvestment & Recovery Act (ARRA) defined Electronic Health Records – Meaningful Use based on five priority pillars:
- Improving quality, safety, efficiency, and reducing health disparities
- Engage patients and families in their health
- Improve care coordination
- Improve population and public health
- Ensure adequate privacy and security protection for personal health information
To engage health professionals in meaningful use, there was a proposition for incentive payments to eligible professionals and hospitals who demonstrated efforts to adopt, implement, or upgrade certified-EHR technology. This was proposed in a staged manner recognizing the potential for imposing administrative burden on health care providers.
As the concept of meaningful use became pervasive, organizations adopted the structure as a mechanism to promote EHR adoption, but also for patient safety, timely documentation, and quality improvement in general. Ask a physician in a large organization today what their meaningful use measures are, and there are likely several levels of meaningful use-like criteria that they are regularly graded on.
How Meaningful Use Relates to Physician Burnout
There is recognition that the cognitive effect of incentive payments in addition to routine compensation can generate a large behavioral response, therefore the basis of meaningful use was well founded. However, in the field of patient care, where physicians nationwide are already opposing the term provider rather than physician, paying for actions which are classically driven by self-motivation and social contract can backfire. Individuals became physicians to care for patients, and paying them to display empathy can be counterproductive, engendering decreased perception of respect by leaders and peers, as well as negative self-worth, thereby contributing to “burnout.”
In January 2017, the National Academy of Medicine, in collaboration with the Association of American Medical Colleges (AAMC) and the Accreditation Council for Graduate Medical Education (ACGME), launched a national Action Collaborative on Clinician Well-Being and Resilience. There are many calls for addressing physician burnout at a systematic level, but importantly, the tools exist to start making changes now. Aligning meaningful use criteria with physician wellness is an important and immediate step which can be taken to improve the physician experience and, thereby, the patient experience.
Improving the Physician Experience
There are several approaches to improving the physician experience. Addressing documentation is perhaps the most effective, and the use of voice recognition tools (some of which can now be performed using the smartphone as a microphone), and in-person or virtual scribes (particularly those individuals or services which also optimize coding) can help ease a physician’s administrative burden while meeting EHR-based meaningful use criteria. The use of default prompts which allow overrides and thereby preserve physician autonomy can also aid physicians in meeting requirements without undue burden.
Equally important, however, is communication. Clearly recognizing why metrics have been chosen, requesting feedback on choices for future metrics, and aligning achievement of those metrics with programs which support wellness both in practice and in presentation, allow physicians to appreciate their worth to the organization as practitioners of the art of medicine, while also including them in the business of medicine.
Dzau V, Kirch D, Nasca T. To Care is Human- Collectively Confronting the Clinician Burnout Crisis. N Engl J Med 2018; 378:312-314.
National Academy of Medicine. Action Collaborative on Clinician Well-Being and Resilience.
Dr. Ami Bhatt is the director of outpatient cardiology as well as adult congenital heart disease at the Massachusetts General Hospital Heart Center where she leads initiatives to provide state-of-the-art subspecialty cardiac care, runs her own Telemedicine Clinic for Adults with Congenital Heart Disease, and creates platforms for virtual cardiovascular care. Her research centers on using medical and patient-reported data to create prediction algorithms for risk stratification and optimal resource utilization.