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Dr. Darrell White's Personal Blog

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Archive for January, 2018

Sunday musings 1/28/18

Sunday musings…

1) Sun. The big yellow one is the sun. Cameo appearance in Cleveburg today.

2) Gentrification. Once applied only to neighborhoods that are taken over by younger, wealthier newcomers than present occupants, gentrify is now applied as a qualifier to anything that is “up-scaled”. Actually, anything that is so much as discovered and enjoyed.

Think collard green smoothies or beef-cheek pirogies.

3) Advice. “Never take advice from someone you wouldn’t want to change places with.” -Kelly Clarkson

Wow. Whether or not that is Ms. Clarkson’s own advice, or if she is passing on the best advice she’s ever received, that’s a pretty power-packed little morsel, would’t you say? I would amend it just a tad because for anyone who is content in life it is unlikely that there is anyone with whom you would do the total switch. How about “only take advice from someone who obviously took their own advice and saw stuff work out.”

4) Meaning. “Pursue what is meaningful, not [only] what is expedient.” -Jordan Peterson

How’s that for heavy advice? What Mr. Peterson is saying, I think, is that one should strive in at least some small part of one’s life to achieve an outcome that is even slightly more impactful than acquiring one’s next meal. Admittedly there is a part of the world for whom there is literally nothing more meaningful than that because doing so might take each waking hour to achieve, but face it, the simple fact that you are reading my drivel is evidence that you have covered the shelter, water, food thing.

So what’ll it be?

I really do think that the search for something meaningful need not involve something that will affect all of human life, though it certainly could. Bill Gates is interviewed in today’s NYT, and Mr. Gates not only has decided to pursue some pretty big, pretty meaningful things, he certainly has the wherewithal to succeed where you and I likely don’t even have the imagination to dream. Still, meaning in actions is there for the taking in endeavors of all sizes. What Mr. Peterson is suggesting is that one be more mindful as we choose at least some of our pursuits.

Today there will be minutes that are up for grabs, as this week there will be hours in play, and this year time for at least one bigger pursuit. This kind of exercise has been part of my make up for some years now, but Mr. Peterson’s elegant phrasing is worth noting for both internal and external consumption. You don’t have to start with something as grand as solving the world’s malaria problem a la Mr. Gates. Practicing, seeking to make more of the tiny actions meaningful, leads quite naturally in my experience to engaging in larger meaningful pursuits. Start small and work your way up.

Start today. Instead of Instagram or Facebook or Twitter tonight, pick up a child and read a little “Goodnight Moon” before bedtime.

I’ll see you next week…

–bingo

Adventures in EMR Vol 2 Postscript: Who Owns This Debacle?

The late, great Larry Weed, M.D., Professor of Medicine at the University of Vermont predicted both the age of EMR as well as the advent of IBM’s Watson, “Big Data”, and machine-learning in the practice of medicine. With the problem-oriented medical record in the form  of the SOAP note (Subjective -> Objective -> Assessment -> Plan) he codified a universal approach to essentially any medical problem evaluated in any patient. What was then called the Medical Center of Vermont implemented a data warehouse which allowed instant viewing of test data by computer throughout the institution ion the early 1980′s (the first “EMR” if you will), and sister institution the Maine Medical Center solved the problem of the handwritten order by adding computer order entry (CPOE) in 1984 or so. Despite all of the hoopla surrounding the Accountable Care Act’s carrot and stick drive to digitize the medical record, the horse was already out of the barn and slowly walking in that direction in the 1980′s.

Why, then, is the EMR landscape such a mess in 2018?

Our American healthcare landscape is blessed with a number of very large, prestigious institutions. They are self-professed and incessantly self-promoted as leaders in both thought and action when it comes to the advancement of medical care in all ways in the United States. It is right here in the laps of the leaders of those famed institutions that blame rests for the debacle that is the modern EMR. As early as 1990 and as recently as 2008 the opportunity to lead presented itself to our most august institutions. When given this opportunity to develop a new, better type of medical record that would aid in every aspect of caring for patients, our most important medical institutions punted.

When you think of the best medical care in the country, who do you think of? Pretty easy to answer that, I bet. The Cleveland Clinic, The Mayo Clinic, Yale, Stanford, the hospitals that made up what has become Harvard Pilgrim Health like Mass General, Brigham and Women’s and Beth Israel, Johns Hopkins, Baylor. Household names, all. Every single one of these institutions seeks to portray itself as the ultimate example of excellence in medical care, devoted above all else to the development and provision of care better than any and all competitors. Not only that, each wishes to project the most pious of images, one that espouses their monk-like devotion to doing what is best for their patients before all other considerations. With a building consensus that record keeping the old pen and papyrus way was hindering both present and future care, and indeed might be contributing to harmful care, the era was ripe for any or all of these presumably noble, altruistic non-profit institutions to answer the call.

When American healthcare was ready to look to any of these institutions to lead us into the digital information age, each and every one of them abdicated. The leaders of these and other great institutions had the chance to develop a true medical record in digital form that was first and foremost a tool to be used to improve the care that was provided in their institutions. They had the resources. Any one of them could have taken a leadership role in its development, not unlike the kind of leadership many of them have taken as the first institution in on cutting edge medical care such as organ transplantation or new generation cancer care.

Instead, both early and late, the leaders of each one of these major institutions chose a path with an eye not toward how the EMR would engage in the care of a patient, but in how it would engage with accounts receivable. Each institution opted to prioritize the growth of revenue over improved care. Everything is about maximizing the income of the institution, while at the same time minimizing the risk associated with billing.

J’accuse.

Think about that second part for a moment. EMR’s are not designed to promote the safety of an individual patient as she goes through her care experience (despite what the marketing brochures may tell you); for safety they are designed to limit the likelihood that a payer audit will find a lack of documentation that supports the charges. The bigger the company making the program, the greater is this emphasis. In the early 00′s any one of the above institutions (and Texas, and Ohio State, and Dartmouth, and…) could have launched a program that met all of the MEDICAL criteria for a good record. If they wanted to make a profit they could have sold the rights to use it.

Why don’t EMR’s communicate with one another? Were you aware that even institutions that run software from the same vendor do not have the ability to simply put notes from one another into a universal chart? Crazy, huh? Frankly I’m not really all that sure who is to blame for that particular bit of nonsense, but the obvious answer as to why your Epic chart can’t communicate with, say, Nextgen lies with that abdication of responsibility I spoke of above.

By not taking control of the process of EMR development at the outset all of our major medical institutions learned that 1) they never really bought an EMR, they just rent it which means that 2) they no longer really own their own information. What better way to remain in control if you are Epic than to prevent The Cleveland Clinic from banding together with The University of Pennsylvania as a bargaining unit than to prevent them from sharing patient information ON THE SAME DAMN PLATFORM?

J’accuse.

To their collective shame our most prestigious medical institutions and their leaders sold their souls by prioritizing their role as commercial entities rather than as leaders in medical care on behalf of patients. In the process they allowed themselves to be enslaved by the commercial interests that now control the medical record. Worse than that they created an additional barrier between a patient and his own medical record.

There has to be a bright spot, right? Some shining beacon, a last bastion, someone willing to stand against toute le monde and defend the honor of academia, to not become the next rhinoceros?  Certainly some institution was willing to stand up and do the right thing by saying “screw it”, we’re gonna make a killer EMR that does everything that Larry Weed said it should do first, and then figure out the billing crap later, right? Perhaps the medium sized Intermountain Health in Utah is on the right track, but all of the really big institutions turned belly up to submit to the demands of payers, hoping for a treat and a  belly rub. Surely UVM, the home of Larry Weed didn’t cave, right? The University of Vermont must surely have been driven by its early entry into the world of digital information management and created its own EMR that both houses information in a clinically relevant way, as well as allowing for computer-guided decision making, right? RIGHT?

Nope. Sorry. The University of Vermont runs on Epic.

 

 

Adventures in EMR Vol 2 Epilogue: May We Please Have…?

“The essence of Medicine is story—finding the right story….Healthcare, on the other hand, deconstructs story into thousands of tiny pieces…for which no one is responsible.” –Victoria Sweet, M.D.

Being forced out of your comfort zone in any endeavor is always painful. In my experience it is also conducive to learning something new, and at least in my case it is a catalyst for creative thought. What, then, have I learned from our forced-march, point-of-a-bayonet transition from one EMR system to a new one? Are there any lessons to be learned on a broader scale, beyond the walls of SkyVision? Can I take this bowl of lemons and create lemonade that can be passed around the much larger table that encompasses the broad landscape of American medicine?

First off, our collective experience with our transition reinforced my long-held contention that you simply can’t effect change in a system of any type without either being a functional unit in that system, or shadowing those who work in the system you wish to improve. Imagine designing the cockpit of the next generation fighter jet without ever actually either flying one or sitting next to someone while they fly it. Take a look back at my essay “EMR and Underpants”; our information ecosystem was designed by engineers far, far away from the point of care delivery. It’s roughly the same as giving someone the job of choosing what underpants to deliver for your daily wear without ever having seen what you look like or talking with you about how you wear your clothes.

After all of our struggles there does appear to be one, huge 30,000 foot lesson in all of this that should, by rights, become the foundation of the next wave of innovation in EMRs: the spoken word is the goal. What made our traditional scribe process so successful in both efficiency and accuracy was the development of charting based on a spoken narrative. The doctor would dictate exam findings. The scribe would then intuit the various diagnoses from the conversation occurring between the doctor and the patient. While the doctor then went on to outline the plan of action this, too, was transcribed into the medical record. It was a natural and familiar way for all of the players in the room to communicate.

Why can’t I do that with any of the EMRs available on the market? Why is it that I can’t talk to an EMR and have my verbal encounter become what we would all recognize as a progress note? Heck, I’d be thrilled if there was an interim step in which all of the BS clicking we are doing to check all of those boxes could turn into something that looked more like spoken English (although our new EMR is OK and getting a bit better on this). With all of the hundreds of millions of dollars being raked in by EMR behemoths like Epic you mean to tell me they can’t find the resources to make this happen? Please.

You see, the essence of every healthcare interaction is the spoken word. When you have to stop talking or listening you have devalued time. Think for a minute from the patient’s point of view: it doesn’t matter whether it is a doctor of some other kind of worker in the room, once attention is shifted from the patient to the screen quality plummets. Make me a poor man’s AI interface that I can cue verbally to let it know what I’m doing and put it in the right box so that Uncle Sam won’t ding me for being a poor data entry clerk. I’d even be willing to talk to Mrs. Pistolacklioni about her smoking at every 3 month follow-up for her severe glaucoma (a disease that has no increased risk if you smoked, by the way).

While I’m at it, and as long as we are talking about communicating (cue Paul Newman in Cool Hand Luke), may we please find a way for the real medical record to be freely available on every platform? Seriously, how did this one escape the cloistered engineers and double-blinded underwear salespeople? Your Samsung cell phone can call your buddies iPhone and vice versa. An airman flying a MIG 22 can communicate with an inverted Tom Cruise in a 3g dive because there is a single standard for radio transmission and reception. Come on. This is basic stuff, the equivalent of declaring the gage of railroad tracks. You mean to tell me that the same people who think they know so much about how things must be that they have an opinion on the shape of operating room hats somehow missed this? Again. please.

I’m not kidding about the OR hats by the way; some DA administrators simply declared that bouffant hats were safer because they think so and won’t come off that even in the face of randomized control studies to the contrary.

Seriously, go all the way back to Dr. Larry Weed at UVM in the 1980′s and return to his beloved premises. There is too much information to be contained in any one doctor’s head, and doctors cannot avoid their biases and frame of reference when making medical decisions. Having true interoperability across all platforms would allow the free movement of information at the direction of the patient, the person who should be in control of that information after all. (Note: Carbon Health is on to something)

As a society we’ve allowed ourselves to remain captives of the trial bar’s defense of the status quo when it comes to malpractice lawsuits. This, in turn, has prevented us from examining repeating errors to determine if there might be a common thread that could be altered and thereby reduce their frequency. Interoperability would allow just the sort of root cause analysis that is needed, and because it would be done using anonymous information no actionable disclosure would be necessary from the doctors involved. As a bonus this would probably allow us to create true, vetted care protocols for the majority of patients with the majority of problems, and this evidence based care would then have to be admissible in court. All that would be necessary would be for doctors to explain in their chart why they decided to deviate in an individual case if that came up. Bingo, a data-driven solution to defensive medicine, all from better communication.

My new vendor is unaware that I am writing this, but interestingly has invited me to consider joining their advisory board and to speak at their annual convention. Who knows if those invitations will continue to be extended once they read this, but if they are I will have two very simple, very basic messages. This whole medical record thing should be about communication, just like it’s always been from the days of Hippocrates. That, and that Larry Weed was right. Before we go any further forward go back and read Larry Weed.

All we need is a little electronic SOAP to clean up this mess.

 

Adventures in EMR Vol. 2 Chapter 3: Jogging in Quicksand

Being an eye doctor in 2018 means that you will take care of patients whose care is covered by a government program of some sort. In order to be able to get paid for your labors you need to record your work in an electronic medical or health record (EMR), and that EMR must be able to comply with  certain diagnosis and quality reporting standards. Failure to comply with these requirements does not mean you can’t take care of these patients, nor does it mean that you won’t get paid for doing so. It just means you will eventually get paid roughly 22% less for that work than someone who has an EMR that does comply.

15 months of effort to get our legacy system into compliance led to 3 months of research culminating in the purchase of a new EMR with a very sophisticated, dedicated ophthalmology/eye care format. With our purchase came on site training (with overtime pay for staff) and literally hundreds of man-hours of preparation work (on the clock) performed by both staff and doctors before we went “live”. The entire adventure was nothing less than a series of “OMG, you have GOT to be kidding” surprises for each one of us, starting with this killer: I would have to pay to retain access to the information SkyVision had gathered on our patients over 13 years. Yup. You heard that right. Even though we would never enter another electron of information into our old system, in one way or another I was going to have to ransom my own medical records.

As embarrassing as it is to admit it, I probably own that particular surprise. Really shoulda seen that coming.

What I also didn’t see coming, indeed what none of us saw coming, was just how different it is to practice medicine in the age of EMR. From Hippocrates through Osler and on to Marcus Welby and whatever the name of the doc played by George Clooney in “ER” was, medical care proceeded in the same orderly fashion. Once again we have Dr. Larry Weed to thank for codifying this process in the form of the SOAP note. Subjective -> Objective -> Assessment -> Plan. You listen to your patient’s story, cataloguing her symptoms and their salient characteristics (onset, severity, duration, etc.). Next comes the collection of data including your exam findings and any test results you may have. From this accumulated knowledge you make a diagnosis, or at least assemble a differential diagnosis, either of which launches a plan of action. The flow is so obvious that it’s somewhat astonishing that it took Dr. Weed to publish this as a process breakthrough.

From the minute we sat down with our laptops and tablets in front of us to learn how to use our new EMR, every single SkyVision staff member fell through the looking glass into a world gone, at best, sideways. Charting to billing, documenting everything that goes into taking care of a patient from the primary point of view of the payers, renders the SOAP model moot. Everything begins and ends with the diagnosis, the Assessment in SOAP-speak. What you plan to do comes next, and you now have to justify what that will be by demonstrating that the diagnosis can be found in the data. Your patient’s complaints have to be explained by your findings. Our tidy little straight line progression handed down from Hippocrates has been scrabbled. SOAP has become APOS.

How perfect is that?

Everyone is aware of how time consuming it is to enter data into a compliant EMR. There is just an endless number of boxes to click, even if you ignore the nonsensical sections that apply to worthless quality measures (childhood vaccine history review at the dermatologist? Smoking cessation at every eye doctor visit?). Even with the pre-loading and on-the-fly development of protocols that “pre-fill” all of the boxes for very common evaluations (e.g. cataract surgery in my world), it just takes a boatload of time to enter all of the information that is demanded. I hear those clicks in my sleep.

Remember, I already used scribes to enter information; if they are slowed down patient flow slows down, too. If I stay and enter information myself my schedule backs up downstream. If the scribe stays with the patient in the room after I’ve gone on to another patient there is no place to put the next patient in line. Leaving the charts “open” so that they can be “finalized” later is an option, of course, but one with three penalties. The practice gets socked with overtime expenses, the staff is overworked and can’t be home, and believe it or not that open chart is “timed” as a quality measure as if the patient was there waiting all that time. Doing a better job ends up dinging your quality score. Merde.

So what did we do and how did it go? We started 5 months ago with 3 charts in the new system per doctor per 1/2 day session. Sounds pretty reasonable, huh? Ease your way into it. Try not to upset the whole apple cart. Maybe just bruise an apple or two. The plan was to slowly increase the number of charts filled in the new system each week by slowly expanding the type of visits we recorded. You know, post-ops before massive, complex pre-op evaluations. New patients who didn’t have any data in the old system. It sounded pretty good when our trainer suggested it. Naturally, as soon as we expanded our universe of new EMR patients we crashed the entire office flow. What had been a finely tuned machine that seldom ran even five minutes behind on a single patient became a battlefield filled with folks waiting 30, 40, even 60 minutes for their exams within an hour of the opening bell.

It was like jogging in quicksand.

I’d really love to tell you that 5+ months in it’s all unicorns and rainbows. That we are now up and humming along, seeing the same number of patients we always have and running on time like we used to.  I’ll admit to occasionally coming across a random footprint that might have been left by a unicorn, and every now and again we catch flashes of color, a rainbow seemingly just out view. We had to hire a part-time tech to assume the task of “pre-populating” the new EMR charts with information from the old system. Every staff member has had to drop parts of their duties to take on the tasks of entering patient information on the front side or finalizing the chart entry so that it is consistent with our billing on the back. I will have to buy access to my old records in the old format, at least temporarily, so that we don’t get slowed down learning a new way to look at old data.

The best way to describe where we are after 5+ months is that we are now running rather than jogging in that quicksand. Exams that once kept a patient in our office for a maximum of 67 minutes now take closer to 90 (we really do track that kind of stuff). Where we rarely had a single patient more than 15 minutes behind schedule we now routinely have  5 or 6 who run an hour late every single day. A couple of week ago I was worried that this one change was going to drive us out of business because of the increased costs, and what I assumed would be mounting ill will from patients who were disappointed in their wait times and stopped coming to see us. Not gonna lie, it didn’t look very good.

A funny thing happened on that road to ruin paved in quicksand: my staff and my patients collectively said “no way.” Crazy as it sounds, two groups of folks who were suffering alongside me looked at the alternative and said “no”. Oh sure, there were certainly patients who trashed us on rating sites because we ran late on a single visit, including some who’d given us straight 5 out of 5 stars for years. But most of them read our “Under Construction, Pardon Our Dust” signs, gritted their teeth, and basically said that we’d earned their patience. Staff is coming in early and staying late. They are huddling and brainstorming ways to restore our flow. Our charting is no better than before but we do send out better letters. Some day we may even be able to do some of those things that Larry Weed talked about when it comes to managing large amounts of information and making complex decisions.

But for now it’s still nothing but pain. It’s hard and the hardship is slow to abate. We all feel the sense of unfairness, that we were forced into this position, and that what we have now does not make our patients any better off than they were before. I would not have chosen this path, not for any reason, had I not been forced to do so. I have no idea, and I will never know if it would have been easier had I picked the other option. Beware all ye who travel here. You are about to embark on a journey where each step is taken in quicksand. It will be a long, long time before you are cleansed of the residue.

Remember, your SOAP has been replace by APOS.

 

Is There an Optimal Age?

Last week I got a bit sidetracked with the main focus of Sunday musings. Nuclear attacks will do that to a body. I’d run across an article on WSJ.com in which a fascinating hypothetical was proposed: If you could stop the aging process at a particular point in time, at what age would you do that? At what age do you feel that you are close enough to your physical peak that you are comfortable balancing that against your intellectual capacities and maturity? Great question, that.

My physical fitness has been slipping for at least several years. Despite this I remain generally stronger than I was at any time other than my years as a college football player. When did I peak? At what time was my overall physical fitness, when my capabilities across the 10 general characteristics of fitness at its highest level? Although I didn’t know it at the time I probably peaked somewhere in medical school. My buddies and I managed to cram in marathon hoops sessions, round robin squash fests, and an admittedly conflict of interest laden exploration of 1980′s aerobics classes (most of my friends were single) while we finished up school. I supplemented this with pretty standard issue weight training (Mrs. bingo like lifting, even back then). Make that peak age 25 or 26.

Believe it or not, from there the slow age and career inflicted decline began in earnest. Had it not been for that Men’s Journal article in December 2005 I’d likely be a typical 58 year old desk jockey, broken by my job and the various and sundry weekend warrior injuries I would have doubtless suffered. Ah, but this CrossFit thing not only saved me from that but also gave me another peak somewhere around age 48. To be truthful I’m back on the descent now, but at least summited another (slightly lower) peak before starting the slide.

How about the other half of the equation? The part where you have a certain amount of intelligence, experience, and maturity? Well, for sure I was whip smart at 26. Every doctor is simply brilliant on med school graduation day; we have no idea what we don’t know, and no idea how to actually be a doctor, but hey, we just crammed for 4 straight years and our brains are busting at the seems with, you know, smart stuff. You know where this part is going, of course. At 26 I’d yet to acquire the maturity and experience that is necessary to create what I’d like to call “actionable intellect”. Such a thing could also be called “judgment”, and in short the ingredients you add to the mix are mileage and the accumulated humility that one acquires “on the road”. Like every other 26 year old I was pretty sure I knew it all already, but we all know how much longer the story is at that point, don’t we.

So it must be age 48 then. Another physical peak achieved. lost of miles under my belt including the humility of a struggling business and the grounding effect of nearly losing a child. Must be 48, right? Well, to be quite honest, I would really love to return to age 48 in a physical sense. My 58 year old bones are more than weary, and I’ll admit right now that I’m slow-rolling writing this because I’m dreading the WOD that’s gonna happen right after I hit “comment”. A funny thing happened on the way to my “final answer” though: I realized that my non-physical growth over the last 10 years has been extraordinary.

It’s not that you have to forgo all of the wonderful things in life at your chosen “stop age”, but the proposal in the exercise is to choose an intersection where the combined peaks were some kind of best. The truth is that my non-physical fitness has continued to grow at a rate which is far, far greater than the rate at which my physical prowess has declined. I have learned, and become so much better at things like empathy, acceptance, caring and the like that there are times that I wonder how anyone ever put up with my younger version. 10 more years of loving and being loved by Mrs. bingo. Of learning how to continue to love other people in my life despite their (or my) faults.

And joy. Oh my, learning that there is joy to be had out there if you can spend just a moment and let it come to you. My little Man Cub has taught me that. At 48 I really had no idea just how much joy there could be. No, for me at least I don’t think I’ve hit that magical intersection of mental growth and physical decline at which I can say I’m at the optimal point. So it’s off to the gym for me so that I can stave off decrepitude just a little bit longer, to give myself a chance to enjoy whatever non-physical growth I have in me yet.

The Man Cub is bringing his family over to play later on and I’ve gotta be ready.

 

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.

On the Beach 2018

(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?

As it turns out this kind of hypothetical is not solely the enterprise of the nuclear age. In fact a Parisian newspaper asked essentially the same question of its readers in 1922, long before the dawn of the nuclear age. Marcel Proust, the famous philosopher, offered perhaps the most lovely response I’ve heard before or since. “I think life would suddenly seem wonderful to us if www were threatened to die as you say. Just think of how many projects, travels, love affairs, studies, it–our life–hides from us, made invisible by our laziness which, certain of a future, delays them incessantly. But let all this threaten to become impossible forever, how beautiful it would become again!”

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. Again, Proust: without the cataclysm “we find ourselves back in the heart of normal life, where negligence deadens desire. And yet we shouldn’t have needed the cataclysm to love life today.” 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.

Greater personal meaning will come from Proust: I will seek my people every day, for it is with them where lies joy. It is for others to seek the greater societal and geopolitical meaning and impact of yesterday’s blunder.

 

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.

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