Go to the Gemba on Meaningful Use
A key feature of Lean management systems is going to the site of the “original work” to study how things are done and how changes affect operations. In Lean lingo, it is called going to the Gemba — an anglicized version of the Japanese word meaning “the real place.” While I was writing about the Stage 2 Meaningful Use (MU) regulations for electronic health record (EHR) incentive payments, one of my neighbors stopped by. As she is a nurse at a large famous academic health system, I quickly turned the conversation from kids and gardening to what was happening around Meaningful Use at her job. What she told me perfectly illustrated the problems that happen when regulations are issued without the ability for the regulators to go to the Gemba. A basic Stage 1 Meaningful Use requirement is that patients be issued a printed after-visit summary (AVS). This should include a consolidated medication list. Sounds simple, right? However, at this large and very well respected large academic medical center, cancer patients were not getting their AVS because of a dispute between departments about which department was responsible for consolidating multiple medication lists into one. Nurses, like my friend and neighbor, were printing the AVS documents and then filing them instead of handing them to the patients because they did not yet have a single consolidated medication list attached. Not only was this a huge waste in paper, time and resources that provided no benefit to the patient, it was also potentially a way to manipulate the data trail to get the hospital its Meaningful Use incentives without actually following the intention of the regulations to better inform patients. The ACR and others have raised concerns about the aggressive timeline in the Stage 2 Meaningful Use objectives affecting imaging, such as access to radiology images and reports through EHR systems. The Meaningful Use objectives sound reasonable, even when the HHS Office of the National Coordinator for Health Information Technology (ONC) acknowledges in the final rule that “many advances in infrastructure are needed to fully enable this objective.” However, the ONC is unable to go to the Gemba to see the impact of its regulations. In addition, it is further insulated from the Gemba because its regulators must my necessity view with a skeptical eye the often well-intentioned legitimate concerns of eligible providers and hospitals since they have a financial stake in the rules. If a simple requirement like the AVS can be implemented incorrectly at a leading academic medical center with vast resources, what may happen with the more complex requirements in stage 2 is a big frightening. Undoubtedly the ONC is right that things will eventually be worked out over time as necessity is the proverbial mother of invention. However, the working-out process need not be quite so messy.