Should pathology be exempt from EHR requirements?

There's a new bill in the House of Representatives that seeks to exempt pathologists from the meaningful use requirements of electronic health record implementation. The bill, HR 1309, would allow pathologists and other specialists to avoid penalization for not adopting EHRs that meet national standards for "meaningful use," standards that many believe are not applicable to their specialty. In the broadest of terms, "meaningful use" is a listing of features/abilities in EHRs that enable structured data capture and sharing — either within a department, a facility, a state, or even a nation (for more specific criteria and elements of meaningful use, please check out this site). It has been a fairly contentious aspect of EHR adoption as facilities (and physicians) have had to meet the criteria in order to both receive incentive reimbursement payments for health systems and to avoid being penalized for choosing EHRs that don't meet the requirements. While this particular bill isn't commenting on the need or value of "meaningful use" in a broader sense, it is questioning the efficacy of such blanket requirements in the face of an increasingly segmented healthcare landscape. The question is, should pathology (and other specialties) be exempt from meeting these requirements?

The arguments for exemption have been voiced by many specialists, most noting that many of the specific objectives/tasks simply are not applicable to their workflow. For example, pathologists who work on surgical samples rarely have any direct interaction with patients and thus would be unable to answer questions about a patient's preferred language, prescriptions, or other similar details. Therefore, even if a lab purchases a certified (and, most likely, expensive) EHR solution that meets the meaningful use standards, the pathologists may not be able to fill out these fields and would thus face various penalties. Of course, they could speak with the patient's other physicians to get some of this information, but that would disrupt the workflow and also slow down the expediency of delivering results. In short, pathologists would be scrambling to collect information that has no bearing on their expertise or their work just to avoid penalties that were designed with general physicians in mind.

The arguments against exemption, however, are a little bit harder to define. There's the oft mentioned boogeyman of slippery slope - when you start exempting one group, it's not long before you exempt many many others. And while it may be an inexact tool in practice, the goal of meaningful use is still admirable: to ensure that complete profiles of patients are created and thus readily shared with other professionals. This goal is meant to not only bolster improved care to the patient, but also to create a larger database from which population-based research can be conducted to provide improved insight into health trends and improved care to meet those trends. If there is a growing group of exempt participants, that means a growing gap in that library of data and thus a decrease in its effectiveness.

Others argue against exemption because they worry that a large tool for incentivizing use of electronic medical records will be taken away, and thus fewer labs/pathologists will adopt these systems. By defanging the law, some say, pathology and other specialties will simply not elect to get these systems which will result in even less information being captured in a structured, standard way and of use to other physicians. It's probably true that, with this exemption, less pathologists will elect to purchase these expensive health systems. However many pathologists already capture vital information in a structured data format thanks to requirements of the College of American Pathologists (CAP). In order for cancer programs to remain accredited, CAP, through the governing body of American College of Surgeons Commission on Cancer, requires that labs do a certain percentage of their cancer reporting using synoptic templates (the eCCs). This means that many pathology labs/facilities/programs are already capturing the information in a standardized way and thus should be transmitting the data uniformly. However, not every specialty has such reporting requirements — and this exemption is for many specialties, not just pathology. Unfortunately, the meaningful use standards do not include a relevant standard such as eCC for pathology, which would be far more applicable to the specialty than tracking allergies and medications.

As of this writing, it's unclear whether or not the bill will pass. And just as unclear is whether, ultimately, pathology should or should not be exempt from meaningful use. On the one hand, the goals of the program are admirable and require adherence to some form of standard. On the other, that standard already exists in pathology and too often we've learned that blanket solutions rarely work for a nuanced industry like healthcare. Healthcare is a sector that constantly moves from the micro to the macro and back again — a patient's symptoms are indicative of a growing trend in a population, and treatments for one patient's issues are derived from many years of many physicians working with a wide variety of patients. And so that balancing act becomes even more precarious once large governing bodies and sums of money are involved as well. In the end, physicians need every tool at their disposal to offer the best care possible, and the government needs to enforce some quality of care without infringing too much on those physicians' efficacy. Hopefully such a balance can be struck.






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