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Dr. Darrell White's Personal Blog

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Archive for January, 2018

Adventures in EMR Vol 2 Chapter 2: The War of the Roses

Unsportsmanlike conduct, piling on should have been the call, but alas, no flags were thrown. After roughly 15 months of crossing our fingers and hoping that our original EMR vendor would be able to guarantee our compliance with the twin pitchforks of ICD-10 and quality attesting it became clear to us that we could no longer afford our “spend and pray” strategy. We felt forced to initiate divorce proceedings with our legacy software and begin the search for a new program that would ensure our compliance, and in so doing allow SkyVision Centers to survive as an independent entity.

Well, that’s what we thought we were doing anyway.

Our original search for an EMR program in 2004 was undertaken from a position of strength in the skinniest of markets. There were only a few vendors who made a product suitable for eye care, and we were making a “want” buy rather than a “need” buy. In this position we had the luxury of working with the ultimate game plan: we could play to win. By this I mean we could clearly state what our objectives were and lay out in clear terms how we expected our new EMR to enhance our business. I mean enhance in every single manner, most definitely including the bottom line. Our search was meant to bring in technology that would not defend against loss but to help us bring in more revenue, to help us win.

SkyVision Centers entered the eye care market with a single, borderline maniacal focus on enhancing a patient’s experience in the office. Face it, there is no way that any but the most sophisticated patients are going to be able to differentiate between doctors and practices based on quality measures having to do with outcomes and safety. Our medical world is quite opaque in ways both inadvertent and purposeful. Discussing “bad doctors” or “bad hospitals” just isn’t done. By the same token, touting better outcomes or safer care is considered borderline slander by other doctors and institutions. Hence we simply considered all of this–quality, safety, etc.–to be the “table stake”, an assumption that each patient made, and we decided to set ourselves apart by our focus on how each patient FELT during their care.

If you think about this, we should also  be able to make all of these assumptions about something as basic as an EMR, right? That it should enhance both the doctor’s and the patient’s experience during care, or at least not have the opposite effect. Our original EMR was quick and efficient, was adaptable to our existing care and process protocols rather than the other way around, and allowed us to maintain eye contact with our patients for >90% of any care experience in the office. This, more than anything else, explains why I hung on for so long after any objective outsider would have already jumped ship to a new, regulatory compliant program.

It took precisely 90 seconds to realize that our patient-centered ideal was going to take a hit by changing our EMR. That’s how long I had to listen to the consensus best patient/doctor interface among the “modern”, compliant programs. Every single program arrives with a pre-set protocol, an indelible and unalterable set of mandatory processes that you WILL implement into your practice. Another 90 seconds spent reading the front page marketing pitch of this new batch of EMR candidates makes it clear that you are not looking at a program designed from the doctor/patient interface out to the billing office on its way to the payer. Every single product now sold that will comply with the various and sundry “quality” and reporting requirements is built from the billing interface back to your exam.

That’s an awfully tough pill to swallow.

Let me take just a minute to address the subject of scribes, staff members whose job it is to transfer the data that a doctor obtains and put it into the medical record. The solution to all of the problems created by EMRs is supposed to be solved by using scribes. Many (most?) doctors who are new to EMR are also new to the concept of using a scribe. Not so, though, in ophthalmology, at least at the level that I have practiced since I left residency training. For the most part I have had a scribe in the exam room with me from my very first day of practice. Our scribes were not just Carol Burnett Show era secretaries but highly trained technicians who simply rotated through their turn writing exam findings, diagnoses and plans with a pen on paper. I’ve always had this, and we utilized scribes in EMR v1.0 as well. Part of the unfairness was that I anticipated the need to hire MORE scribes simply to tend to the software’s protocols, so we were losing before the game even started.

What then does it mean to be playing “not to lose” when choosing the next EMR? The very first premise is little more than trying not to lose money you’ve earned by receiving a penalty for inadequate fidelity to all of those reporting rules. After that it becomes something more like trying not to lose your soul. Which program would allow us to maintain as much of our substance and our style while allowing us to continue to take care of the same number of patients? I was willing to forgo growth (loss #2 before game time). How long would it take for us to transition between platforms? Was there a program that would let us go fast enough that our patients would forgive us the obvious change in what it felt like to be in the office, even if that change was a 25-50% longer experience? I mean AFTER the transition. 25-50% longer in the office AFTER we are good at the new program. That was the reality I encountered in my search.

I’m not gonna lie. My biggest fear was that I would choose the wrong program. Well, check that; my biggest fear was that I would choose a program that would hurt us more than another one I might have chosen. I did my homework. I reached out to colleagues who do what I do and had chosen an EMR in the last 3 years. I went into offices and watched staff members and doctors use the programs I looked at. It was unbelievably depressing in all honesty. The lack of eye contact with patients and the slavish attention demanded by the computers in the room was appalling, not to mention the drudgery. Death by a thousand clicks.

Check that. A million clicks.

A consensus arose among eye doctors, one that I agreed with, that there are two EMR products on the market that are better than all of the other options, and that it is essentially a toss-up between them. Every colleague I chatted with felt this way, including those who were content with their present programs; they would choose one of the two (and not their present program) if they were starting from scratch. After narrowing down my choice to two it was almost a coin toss to be truthful.

After pouring lots of money into that car I already had in the hope of returning it to functionality I was ready to buy a new car. To spend yet more money on one of the two choices before me. No matter which one I chose, I was choosing something that would mean an existential change in how we practiced medicine at SkyVision Centers. Because there were only two, no matter which one I chose I would forever be haunted by the question of whether life might have been just a bit less unpleasant if I’d chosen the other one.

Changing your EMR because you have to is like the War of the Roses: there is no winning or losing, there are only degrees of losing.

Next Chapter 3: Jogging in Quicksand (where only the “A” counts in SOAP)

Adventures in EMR* Vol 2 Chapter 1: Government Forces a Divorce

It’s hard for me to empathize with docs and medical organizations who as late as 2015 0r 2016 lamented the U.S. government’s irresistible demands to electrify the medical record and had not yet done so. Along with the other follies imposed on all quarters in healthcare, the Accountable Care Act (ACA) spawned in the early days of the Obama administration decreed that all care provided to patients covered (paid) in any way, shape, or form by the federal government must be recorded in electronic (computerized or digital) form. More than that, this digital health record (EMR) must conform to the nebulous and ever shape-shifting requirements known as “Meaningful Use” (MU). Armed with 30 pieces of silver on the front side and the promise of slow, withering financial ruin on the back, CMS went about the business of coercing organizations large and small to move from paper to electrons.

Why, you ask, if I am so obviously disdainful of this occurrence, do I find it hard to empathize with folks who’ve been harmed by this process? Well, our group SkyVision Centers (SVC) saw the value of using an EMR at the time of our founding in 2004, back when Mr. Obama was a very junior Senator from Illinois and about to be “discovered”. The concept of an EMR, with the medical record warehoused in a server rather than in a folder, was so obvious to us at the time that we never considered the use of a traditional chart as we developed our bleeding edge business plan. As a University of Vermont grad I had learned about medical information processing at the knee of the great Larry Weed. Indeed, my biggest frustration with the EMR’s available in 2004 (and still to a degree in 2018) was that they did not allow me to do the kind of information processing that I learned from Dr. Weed’s associate Dennis Plante, who taught me about computerized medical decision making in 1984.

Those doctors and those medical groups that were still using a traditional paper chart in 2015, 16, or 17 missed the boat by 10 years; their enhanced pain brought on by their inertia was self-inflicted. More than that, the larger among these groups (I’m looking at you, UPenn) essentially recused themselves from leadership positions that they could/should have taken. As an aside which I will explore in an epilogue to this series, very large early adopters (think Cleveland Clinic, The Mayo Clinic, and Harvard Pilgrim Health among others) bear a significant responsibility for the mess we now find ourselves in by abdicating their leadership role as medical institutions in favor of maximizing their return as business entities in the earliest days of EMR.

Back in those UVM days Dr. Weed built his case from two very specific premises: there is simply too much medical information for any doctor to be able to house it in his/her brain, and decision making based on the data available for any one patient is too easily influenced by a doctor’s frame of reference and biases. Sounds familiar, especially if you spend any time on Twitter and follow folks like Vinay Prasad, Saurabh Jha, and Amitabh Chandra. Dr. Weed clearly envisioned a universe of connected records (mind you, this was well before anyone outside of the government  had heard of the internet) that would allow the free interaction of multiple doctors with all of the information available on any patient. Without using the word Dr. Weed described “interoperability” perfectly. (Note that UVM had all testing results–radiology, lab, etc–available on computers in the 80′s. Sister hospital Maine Medical Center one-upped them with computerized order entry in 1983.)

Mind you, most of this was not really available in 2004 when SVC was looking for its EMR. We just assumed that it would eventually be programmed into a larger system as more doctors and practices saw the light. Our rationale for implementing an EMR at this early time in history was driven by the obvious advantages that it would give us when it came to providing the best possible patient experience when we were taking care of patients with eye problems. Utilizing an EMR allowed us to maximize our efficiency so as to minimize the amount of minutes wasted over the course of a care visit to SVC, fulfilling with our pocket book our mission statement to provide “The Best Experience in Eye Care”. Our specific EMR choice fit seamlessly into our Toyota manufacturing-derived system of workflow and enabled us to vastly exceed our patient’s expectations when it came to the office experience.

We were on the cutting edge. So what happened? Well, in short, Obamacare with all of its regulatory burdens happened. Onerous “quality” measures came and went in the early days of the ACA. My professional organizations as well as the owners of the EMR we’d chosen lobbied vociferously against the implementation of what would have been disastrous burdens on the field of eye care (among other specialties). Back at home we doubled down on our market advantage as the best office experience for our patients and slow-rolled along with our EMR provider as it did the minimum necessary to remain compliant. In hindsight I was clearly choosing efficiency and the maximization of the patient interface with the practice over Larry Weed and the information interface.

We probably could have continued this way if not for ICD-10, the coding change that increased the number and complexity of mandatory diagnosis reporting when billing. For reasons that remain unclear to me our EMR provider could not accommodate the change to ICD-10 in a way that allowed us to properly document our charges for very specific, common eye problems. This is a problem, you see, for eye doctors of any stripe take care of patients who are covered by government-funded programs. Failure to comply now meant penalties that would ramp up to 22% of payments in an industry that routinely runs a profit margin of 25-30%. Each slow step in the right direction was followed by multiple steps backwards and sideways.

We as a group never felt that our concerns and clear business needs were being adequately addressed. Have you ever owned a car that had a serious problem? One that seemed as though it was fixable, at least at the onset? Maybe it was a car that you loved, or maybe it was just a car that was paid for and did the job for you. You put money into the car to fix it and it’s not better, so you spend some more, and then you spend some more. At a certain point you realize that no matter how much money you put into fixing that car you just can’t lose the thought that it’s not going to be enough. You just can’t shake the worry that despite all of that money you are still going to end up on the side of the road at midnight in the middle of nowhere. After months of expensive upgrades that were late in coming it became clear that we could not be guaranteed that the EMR we’d been using since our creation would be able to carry us forward in a financially safe manner by meeting the government’s regulatory demand.

In effect, the U.S. government, through the regulatory demands of the ACA, forced us to initiate divorce proceedings with our EMR. To survive it became clear that SVC would need to buy and implement an entirely new EMR.

Again, you might ask, why can I not empathize with those who are late to the EMR game and suffering the pains of implementing a new EMR into their organizations if we are now in those same, exact shoes? I think it’s a fairness thing, and I fully acknowledge the irony that I am a guy who routinely quotes Scar’s great line “Life’s not faaaiiirrr.” You see, in my mind, we did the right thing way before we had to by spending money we really didn’t have in 2004 on an EMR way before it was mandatory. And we spent. And we spent. As anyone who has ever worked with mandatory software knows, your key critical programs are the gifts that keep giving…to your vendor. For our commitment to providing a better experience for our patients (and admittedly more business for the practice) we would now be rewarded by having the privilege of paying for a whole new system.

And as I will discuss next, paying for the “right” to see all of the information we’d already paid for.

Next Chapter 2: The War of the Roses

 

*Like all good reporting where one hopes to discuss global issues rather than very granular, product-specific issues, this series will not name any products that we have previously or are now using.

Tending Your Culture

“When you decline to create or to curate a culture in your spaces, you’re responsible for what spawns in the vacuum.” –Leigh Alexander

Nature abhors a vacuum. In all ways and in all places. While I have never seen this immutable law applied to group culture that only speaks to my own lack of imagination and insight, and by extension Alexander’s surfeit of both. I use “spaces” a bit differently, preferring the term as a reference to internal or personal geography (timespace, brainspace, emotionalspace). Alexander’s choice of “space” rather than “place” adds to the brilliance, the “aha”-ness of the insight in that it specifically includes the virtual as well as the physical.

Some people exert, or could exert, enormous influence over very large spaces by either actively tending to the culture or by standing aside and simply observing what fills the vacuum. The just-retired CEO of our local medical behemoth has imposed his will at a very granular level on an organization that employs 10′s of thousands. Rules and regulations abound there. The opposite was the case, at least at the outset at CrossFit, Inc. The culture arose primarily from the founder’s libertarian philosophy and worldview. Pretty freewheeling, rough and tumble, then and to some degree now.

Think for a moment about your own spaces, maybe looking initially at the ones over which you might have a bit of control or influence. Work. Home. Third space. What has your role been in the creation and ongoing curation of the culture of those spaces? It’s a rather Taoist proposition, I think: to act is precisely equal to not acting, because one or the other course must be chosen. At my day job we actually did go about the task of creating a culture (A Tribe of Adults), and we knowingly curate that space by culling the tribe of those who don’t, won’t, or can’t acculturate.

In the end this is probably just another entreaty to consciously examine your own spaces, your world, and seek to exert whatever control you can wherever you can in order to live well. Whatever “well” means to you. Again, the Tao te Ching gives us some useful vocabulary, imagery we might reference. We are all more like the pebble in the stream than the reed in the field. We may aspire to live as the reed, flexible and ever able to flow with whatever breeze may blow through. The reality is that an untended culture surrounding us flows so powerfully that it, like the water in a stream, eventually reshapes us as it inevitably sculpts the stone in the stream.

The difference, as both Lao-tse and Leigh Alexander teach us, is that you have the ability to control the flow.

Sunday musings 1/14/18: On the Beach 2018

Sunday musings…

1) Anoesis. A state of mind consisting of pure sensation or emotion without cognitive thought.

Just thought you should know that.

2) Utility whiskey. What you drink after you can no longer tell that you are drinking the good stuff.

YMMV.

3) Smoke. “Where there’s smoke, there’s fire.” What do you do when the whole world is nothing but smoke?

4) Air-gapped. Not connected. As in a computer that is never, not even once, attached to the internet.

Like a book, or a notebook, with a plug.

5) Alarm. (Surely you knew this was coming) This weekend begins the Royal Hawaiian Eye Meeting, an annual gathering of eye surgeons that I have thus far managed to avoid attending every year of my career. Why, you ask? Meh. 6 time zones for 3 days of work is the best answer. If that doesn’t do it I’ll add that Mrs. bingo won’t join me for the trip, and I really dislike most travel without the company of Mrs. bingo.

As you may have heard there was a bit of excitement in Hawaii yesterday. Seems a rather fumble-fingered employee jabbed the “alert all” button when taking his turn at the helm of the Emergency Response Center and sent off a 1960′s style, death from the air is coming, curl up under your desk kids and kiss your ass goodbye nuclear attack warning. Funny (funnier?), the doof figured out what happened when he got a text on his own cellphone.

Note to Expedia: this guy needs his own “Wanna get away” commercial.

What was your reaction? Mrs. bingo is away visiting her ailing Mom so I was alone chez bingo to contemplate what I would have done (interestingly, I would have been alone in Hawaii as noted above for real). The good folks of Hawaii and their 10′s of thousands of weekend guests were handed the dubious privilege of contemplating, if for just 30 minutes or so, how they would spend the last couple of hours of their lives knowing that they were about to spend the last couple hours of their lives. Did this occur to you, too?

Yesterday also brought me a couple of articles in a similar vein. One, from the WSJ, was not quite so stark. It asked when you would take a pill that arrested the aging process. At what age would you decide that the balance of physical prowess and age-begotten wisdom was optimized? (N.B. this was going to be the main topic of “musings”…) I also stumbled across a review of a book or a movie or something in which 3 siblings are told as young children the precise date of their deaths. What followed was the decisions these young children made based on that knowledge. Gotta admit, I went right to that place when I heard about the Hawaiian modern air-raid siren.

T’was a time when this type of inquiry was a rather commonplace occurrence. You could do worse than reading Neville Shute’s novel or the Stanley Kramer movie “On the Beach” based on it to get a sense of what a nuclear fraught world felt like. Both the novel and the movie depict a world destroyed by nuclear war, and life in Australia as the end-of-life nuclear cloud approaches the continent. How and what normal people decide to do in the face of an unavoidable expiration date some weeks ahead is central to the story. Yesterday’s equivalent would have been some hours ahead it seems.

What would you have done? Would you have sought shelter, as suggested, and hoped to somehow miraculously escape incineration if you were at ground zero? (As an aside, can you even imagine the horror of taking part in the effort to get off the islands to escape the radiation? We’d learn what savages we actually are, I fear) Would you go all Sartre or Beckett and choose an earlier “departure” of your own making as did so many in “On the Beach”? If it were real, what do you think you would have done?

I surely know not what came before, as surely as none of us truly knows what, if anything, comes in the end. Questions that arise from the (usually) hypothetical “what if you knew when” scenarios lack the urgency to force an honest appraisal. It will be interesting for me to have a chance to chat with folks I know who are in Hawaii right now (a couple are close friends), but for now it was enough for me to have undergone this thought experiment for the umpteenth time and come to the same conclusion: I would have sought my people. Some how, in some way, with my last dwindling moments I would do whatever it took to be with my people.

It is for others to seek the greater societal and geopolitical meaning and impact of yesterday’s blunder.

I’ll see you next week…

–bingo

We Have More In Common Than Not

Several people of whom I am very fond have recently asked me to engage in something or another about which they are very, very passionate. In truth, my interest in any of these particular things/issues/ventures begins and ends with my friendship or association with the individual. For a number of reasons I just cannot find the time-space, brain-space, or emotional-space to engage in any but the most superficial manner in that which has my colleagues/associates/friends all fired-up.

In no way does this mean that these issues, etc. are not significant or important, it means only that they are not close enough to what is central to my core for me to become involved. Not becoming involved also does not mean that I think any less, or even any differently about the individuals involved. Not at all. That is the point, and more so, that I believe may be the tonic that is necessary to treat the virulent strain of discord that seems to have consumed so much of our discourse whether it be writ large of small.

We all have more in common than not. There are more things that we each hold dearly, that we feel are existentially important, than there are things on which we disagree to a point that we cannot inhabit the same space. This is the 80/20 rule of a functioning society.

Sure, maybe it’s 70/30 or 95/5, but does that really matter? Personally I think it’s more like 95/5 or even 98/2, but that may be a reflection of my worldview or frame of reference (when asked about my Holiday season I tell folks I batted .950). The point is that our commonality is far, far greater than not. If you and I agree on 95% of the things we might encounter but disagree on 5%, is our relationship over? If I do, in fact, agree with you but decide I do not have the time (or the stomach) to join you at the same level of commitment you’ve chosen, are we not able to continue our discourse? When I choose to spend 4 hours playing with the Man Cub and his Thomas the Tank Train rather than take up the mantel of your cause/issue/enterprise I am not really saying anything about those, or you, at all.

Where once Americans separated themselves along only large, even epic fissures (Religion, wealth, race, etc.) we now seem willing to render ourselves asunder over progressively smaller, hairline fractures in a connection. This is sad, and all the more sad because it is unnecessary. Pick a number–80/20, 95/5. Whatever. The solution to many of our social disquietudes lies in choosing to begin your engagement on the side of the larger of the two numbers, that which we have in common, before giving consideration to that which we may not share.

That which we have in common is the greater.

Anti-Elitism is a Dead-End Street

There is an antielitism in the air in much of society, Western and otherwise. It all seems new and shiny and unique to the young, but it’s just that part of the cycle right now. We’ve been here before, we’ll move past this soon, and we’ll get there again. A part of the nastiness of today’s particular version of this antielitism seems to stem from the intimate knowledge that we all have of the minutiae of the lives of the elite, in all its presumed glory. Moreso, a substantial portion of our modern elite seems not immune to the rampant over-sharing so prevalent today. And that just feels like bragging, doesn’t it?

There needs to be room for elite and elitism and elites, though, and there needs to be this room in all walks of life. Even more importantly, there needs to be room for those people who openly seek to become elite, better than most, maybe the best. Elitism is simply a harsher form of “meritocracy”, the notion that one can be rewarded for being better in some way at some thing. Elitism is synonymous with “best”, at least when the elite are gracious enough not to rub the rest of our noses in it (see above).

What’s hard for us who are not elite is to separate our jealousy and our anger at those who are truly elite from a couple of important things. We must realize that, without the elite we would forever be mired at an inexorably static mean. Part of a curve under which the volume never changes. It’s also vitally important that we rein in our apparent need to stop any and all who openly express their desire or their efforts to achieve anything above the mean by aspiring to something elite. After all, who knows which of those aspirants will become an elite thinker or doer, one who will drag us all to a higher mean?

Whether it’s in fitness, or in science or finance or philosophy or letters, the area under the curve is driven upward by someone who had whatever it took to become elite. We can learn from them, become a bit better at whatever it is that we do or we are, if we spent a bit less time seeking to drag them back to us.

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