Meaningful Use, Procrustes, and the Morton's Fork

July 14, 2010
Paul Roemer

"Meaningful use," if used as a way to obtain federal incentive money is at best meaningless, at worst -- without numerous other initiatives -- it can disrupt your business. It seems to violate the dictum, "Do no harm."

This guest column by Paul Roemer, who blogs at HealthcareITStrategy.com, first appeared on HCPLive.com.

I have been invited to write a piece on the implications of electronic health records (EHR) and the new "Meaningful Use" standards for private practitioners.

Short answer: Meaningful Use, if used as a way to obtain incentive money is at best meaningless, at worst -- without numerous other initiatives -- it can disrupt your business. It seems to violate the dictum, “Do no harm.”

There is a groundswell building against meaningful use. How do I know? Because I am starting it. Meaningful Use is an early adopter of the KISS principle: Keep It Stupid, Simple.

In Greek mythology, there was a not-so-nice man named Procrustes. He had an iron bed in which he invited wayfaring strangers to spend the night. Some of the strangers were too long for the bed and others were too short.

Apparently, Procrustes liked things orderly and could be a tad anal when learning his guests did not fit. He would set on them with his smith’s hammer, to stretch the shorter ones to fit. If the guest proved too tall, Procrustes would amputate the excess length. Truth be told, nobody ever fit the bed exactly because Procrustes had two beds.

In contemporary terms, a Procrustean Bed is an arbitrary standard to which compliance is forced. A Procrustean Solution involves fitting a business problem to a preconceived set of strictures.

Raise your hand if you have already figured out where this is headed. Preconceived. Arbitrary. Compliance. Strictures.

Do you spell Meaningful Use with an upper case Procrustean or one in lower case? I prefer the upper case. The business problem being fitted is the implementation of EHR. The preconceived sets of strictures are the Meaningful Use standards.

This in turn leaves the healthcare provider in what is best described as a Morton’s Fork scenario. Shall I explain? A Morton’s Fork is a choice between two equally unattractive alternatives -- a dilemma. The concept originated in 1487 under the rule of Henry the VII as a result of policy to ensure everyone paid taxes. The argument was because the rich had enough money to buy things they must have enough money to pay taxes, and the poor who had bought nothing had saved their money, and thus had money with which to pay taxes. The two prongs of the fork -- back then forks only had two prongs. Q. E. D.

The healthcare provider must choose between -- as one may not choose among -- two alternatives. Attempt to meet Meaningful Use -- a Procrustean Solution -- and turn their business model inside out to meet the government’s Gossamer standards.

Attempting to meet the standards does not ensure they will in fact meet the standards. Should a practice only meet 99 percent of the standards, it loses. The Pareto principle does not apply. There is no 80:20 rule. The practice will not receive any incentive money, as Meaningful Use is an all-or-nothing game.

The second alternative is to not meet Meaningful Use. This choice may be voluntary, or involuntary -- trying to meet Meaningful Use and failing. Alternative Two, it is said, will result in reimbursement penalties from Medicaid and Medicare.

I do not think those penalties will be implemented, or at least they will not be implemented in the documented timeframe.

I also do not think there is a Morton’s Fork, because I think Meaningful Use will disappear because it is so arbitrary and capricious --- and because the number of large providers who will meet it could all drive to lunch at Morton’s in a Yugo, at which time they could dine with a fork from Morton’s.

We have now come full circle. My work here is through.

One last point, if I may. Practice Management System (PMS) -- get one, and get a good one. If it comes with an EHR, that is okay. There are need-to-haves, and nice-to-haves. EHR is the latter. A PMS is the former. The physician practices with which I am familiar are terribly inefficient; paper is everywhere and is handled multiple times. A single practice sends and receives more faxes per day than Boeing. Physicians started their practice to provide care, not to run a business, and this is quite visible.

Sure there are some success stories. Some. For most, the first step is to triage your practice. Install a PMS, and then pop in an EMR. Start with the eLab/eRx portion to build the patient data base, and then add the EMR functionality.

Paul Roemer is a healthcare strategist with more than 25 years of experience in executive management. He is managing partner of Healthcare IT Strategy in Downingtown, PA, and is also Chief Imaginist of the Healthcare Idea Lab.