The Health Information Technology for Economic and Clinical Health (HITECH) Act was included in the American Recovery and Reinvestment Act (ARRA) and was signed by President Obama on Feb.17, 2009 during the depths of the recession. HITECH was intended to promote the adoption and
meaningful use of health information technology, and included requirements for implementation and expansion of Electronic Health Records (EHR's) in medical practices. The HITECH Act set meaningful use of interoperable EHR adoption in the health care system as a critical national goal. The goal was meaningful use of EHRs — that is, their use by providers to achieve significant improvements in care. A variety of timelines were outlined, with incentives for various levels of
meaningful use from 2011-2014 (the Carrot), to be followed by penalties for non-compliance (the Stick), in 2015 and thereafter, for Medicare. Meaningful Use is a complex topic and is beyond the scope of the current diary.
There are many who will blame EHR's on the ACA, but the progressive adoption of EHR's has predated the ACA by many years.
More follows the orange digital Caduceus
An internet search of EHR+physician satisfaction leads to an endless list of complaints and negatives from physicians. Multiple difficulties include but are not limited to: rushed and inadequate training, poor vendor support, poorly designed interfaces requiring multiple taps and clicks as well as typed entries, problems with voice dictation entry, increased time required for record creation, reduced face time with patients. Physicians by and large are unhappy with EHR's. Older physicians with more limited computer and typing skills, as well as experience with decades of efficient use of traditional voice dictation, are especially challenged and frustrated.
Primary care physician (PCP) utilization has been greatly impacted by the move to EHR's. There are many who are worried whether we have a physician shortage. Much more likely is that we have a physician utilization problem. Further study is needed, but probably greater than 50% of a typical PCP's work output does not require postgraduate training and a professional degree, including: computer order entry, prescription processing, billing invoices, filling out test requests, disability forms, referral requests, working an inbox full of random notifications and disconnected results, and typing the visit note. Physicians thus have become the data entry clerks and data processors. How many readers here have the experience of a recent physician visit in which the physician is busily typing behind a laptop, hopefully facing you, or even worse typing on a desktop with his/her back to you?
TOLT is the key acronym. TOLT = Top of License Time. What percentage of the time are physicians and health providers optimally using their professional skills, in contrast to the non-professional tasks listed above? I first learned of this concept in the book "The Doctor Crisis" by Jack Cochran, MD and Charles Kenney, published May 6, 2014. In that book the authors stress the importance that all members of the healthcare team, and not just the physicians, should be functioning at the top of their respective license as much as possible. Credits also to Dr. Sinsky for this excellent blog on the same topic http://www.kevinmd.com/...
Further study of TOLT should help identify the utilization problems within the health care system. I would expect to find that that TOLT is lowest in primary care and highest in procedural specialties. What do you think? In no other industry is the highest trained professional spending much of his/her time on work that others could perform. The current reimbursement system benefits procedure-driven specialties at the expense of "cognitive-driven" PCP providers, that is those who spend face time with the patient and do not peform a procedure. PCP providers are pressured to document a great deal of information to justify a higher billing code under the current fee-for-service Evaluation and Management (E&M) billing process.
TOLT frustrations will be yet another factor to compel physicians to specialize rather than to enter the ranks of primary care specialties. TOLT inefficiency would be hypothesized to result in time pressures on physicians to not only spend inadequate time actually examining the patient after taking a rushed history, but also then taking the "path of least resistance route" in medical decision-making, possibly ordering a costly test when peer-reviewed guidelines would deem that to be unnecessary.
TOLT issues can be addressed by a proactive, team-driven approach to health care. The greater reimbursement for procedure-driven specialists will allow them to more readily employ assistants to perform many of the tedious non-professional tasks. The recent trends in medical practice have included the "integration" (purchase) of PCP practices by larger healthcare entities such as hospitals and insurance companies. Medical leaders need to ensure that their PCP practices are properly staffed so as to permit the PCP providers to function at maximum TOLT.