Email 5% of Your Patients—Maybe the Stupidest Government Idea Yet
February 7, 2017
This is a story of bad government at work.
In 2011, the federal government began a program called “Meaningful Use,” which was intended to encourage physicians to switch to computerized medical records (otherwise known as electronic health records, or EHRs). It was assumed by essentially everyone that having physicians using computers would magically fix much of what was wrong with the American health care system. Nothing could have been further from the truth. The reason is that EHRs were (and still are), for the most part, not ready for prime time. So, the government was encouraging, and then beginning in 2013, mandating, that doctors use software programs that were largely unusable. But the Meaningful Use program itself, because it was so poorly formulated, contributed to the problems. It is a revealing story. My hopes in telling the story are that improved understanding of such issues will help us to someday formulate better ways to govern.
One of the requirements of the Meaningful Use program is that doctors must email with 5% of the patients who have had an appointment. To satisfy the measure, and avoid its penalties, there are three requirements. First, fifty percent of patients that are seen for appointments must be given information that a doctor has a secure on-line patient portal. Part two is that five percent of patients seen for an appointment must register on the portal and view their health information. And finally, five percent must actually send the practice an email. Each of these steps must also be documented in such a way as to generate data to prove they have successfully occurred, and then that data must be reported to the government.
This is a bad idea. Where did it come from? Like many bad ideas, it comes from what was originally a good idea. You see, studies over the years have shown that patients who are more "engaged" in their care, that is, better educated about their health issues and more involved in their own care, tend to have better health outcomes. Armed with such information, bureaucrats came up with this terrible Meaningful Use requirement as a way to force doctors to share information with their patients and to communicate more with them—mandatory electronic patient engagement.
What are the problems with this approach? First of all, emailing with patients is not the same as being “engaged.” Engagement is a broad concept. Communication is one aspect of engagement. I agree that doctors should be encouraged to share information with patients and to communicate with them. For many years, if a patient called my practice with a question, I have tried to call them back to discuss things with them. It works for me and for my patients (I have never been paid a penny for this, by the way). Forcing me to email with patients five percent of the time, though, is such a narrow interpretation of the concept of engagement. I think it will have no effect on health outcomes. Also, it is such a heavy-handed helicopter-government approach that speaks of the worst aspects of this bureaucracy, which gets far too involved in our professional lives. It is an aspect of government that many of us viscerally dislike, and for good reason. There are so many ways that the government could help patients be more health literate and engaged in their care. This misses the point and scuttles an important opportunity to do things effectively and helpfully.
But that's actually the least of the problems created by this silly regulation. Requiring that physicians get five percent of the patients they see for appointments to sign up to their portal and to email them, and attaching a potential monetary penalty for those that fail to achieve compliance, carries a number of unintended (hopefully unintended) consequences. Creating an artificial need to email with patients means that doctors will actually have to spend time encouraging patients to send them emails! What a stupid distraction! In response to this requirement, doctors and health systems have begun sending an email to 100% of patients after they have an appointment, asking things like, "Hey, how are things going?" The doctor then often (hopefully five percent of the time) receives an email back with such helpful comments as, "I'm good, how are you?" So, now physicians, already too busy attempting to do their work and to comply with other silly government requirements, have to spend time participating in potentially inane email back and forth with their patients.
Further, such a requirement penalizes doctors who care for the oldest (and often the most difficult) patients, who tend to be the least likely to use a web portal or email with their physician.
This is the essence of one form of bad government. It creates a new layer of administrative burden, and likely achieves very little towards the ultimate goal of improving patient outcomes.
But it is not the type of thing you hear being discussed by politicians or the media. If you listen to them, the argument is all about the appropriate size of government. But it is not just about size, but about the methods this era of bureaucrat utilizes. If we hope to improve government, we need to examine issues down to details such as those in this story. We must ask and answer how government can effectively achieve its aims without always making such a mess of things.