Random Thoughts from a Restless Mind

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 in the early 1980’s (the first “EMR” if you will), and sister institution the Maine Medical Center solved the problem of the handwritten orders 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.

Thinking about that charter school for inner city boys where the study of Latin is mandatory…

In my day job I work with folks of various backgrounds, both in terms of education and upbringing. In all walks of my public life I come in contact with an even broader swath of humanity in all regards. I routinely travel up and down the social, economic and educational ladders at work and at play. For the most part, with everyone I meet the language we all speak is English. I live in Cleveland, Ohio, USA after all. Our English, however, is hardly the same.

While we cannot truly escape our origins, as we cannot truly escape our genome, we can choose how we interact in the daily mechanics of society regardless of origin. For better or for worse this begins with how we speak. That old saw, you only get one chance to make a first impression, is especially true when you speak, and especially important because for the most part you can choose not only what you say but also how you say it.

There’s nothing new or striking about this concept, either. You can think of it as verbal situational awareness. You would (hopefully) speak differently to a priest than you would the surfer dude sitting next to you beyond the break. On the phone with the cable company should sound very different I think than on the phone with your BFF. All speech is by definition qualitatively different than a text or an email because speaking implies hearing; speaking and hearing involve the inclusion of inflection, tone, and tempo. Really basic stuff.

Why, then, is it so brutally common to hear such poor English? Poor grammar, improper word usage, a situational tone-deafness? This doesn’t even begin to touch on the concept of working vocabulary (BTW, the person with the largest working vocabulary I’ve ever met is responsible for my  little CrossFit thing). Once upon a time one heard much about “Proper English” or “The Queen’s English.” What happened?

In English we do not have the French equivalent of “Tu” vs. “Vous”. No lazy man’s way to “polite-up” our speech. A certain unearned familiarity is too often presumed. We take way too many liberties with grammar, and frankly we too infrequently make the effort at “polished” English when it’s time to do so. That first impression thing is incredibly affected when you open your mouth to speak, on the up and the down sides. It is equally jarring to hear the word “ineluctable” from a guy in faded jeans and a baseball cap turned backwards (up) as it is to hear “me and Joey are gonna go…” from a guy in a suit and starched collar (down).

The stark reality is that there are no barriers to the “up” version of English. There is no genetic, social, or economic barrier blocking the acquisition of the ability to speak well, and by extension to acquire the situational awareness to know when it is vital to do so. All that is required is the effort to learn that version of English that we know as “proper”, and the effort to learn when. Those young men learning Latin at that charter school are off to a great start. It’s not necessary to speak like this all the time. You can choose to “let your hair down” so to speak–my love for the versatility of the “F-bomb” is well known in certain circles–but a lack of virtuosity in the English domain is a choice.

There are many aspects of a “first impression” over which we may have little control. Don’t choose to let your English be one of them.

There is a certain arrogance in the academy, that vaunted group of professors who opine righteously from afar about pretty much anything they study. Add to that the well-known arrogance of youth with its inherent disregard for any and all history which transpired before the youthful reached the age of cognition and you have either a toxic combination of ignorance and impetuosity, or simply a laughably vacuous collection of paper thin pontification. Such is the case with a series of statements quoted yesterday morning from a lecture given by a young academic physician on the state of population or public health in America. He posits that there is a new movement toward moving healthcare from inpatient to outpatient. There is an equally new and heretofore unseen effort to make people healthy rather than treat them when they are not. This young doctor is calling his observations Population Health v1.0.

I’m calling it Bullshit.

The lecture in question was being live-Tweeted, but that is probably the only thing about the subject matter that can reasonably be v1.anything. Instantly available dissemination of medical information to a general audience is a truly new phenomenon. With it comes the danger of the wider audience simply accepting the information since it comes from an “expert”. However, along with the relatively naive broader audience we thankfully have a small subset that is either a) informed enough on the topic to offer a “con” opinion, or b) simply old enough to remember that there is a deep and meaningful history that predates what the young expert is proposing as new. Count me as able to check c) both of the above.

Population Health is simply a better term for what historically has been known as Public Health. While Public Health typically connotes some sort of governmental involvement, Population Health is a more inclusive, more powerful concept because it includes not only government programs but also private initiatives of all kinds. Public Health typically equates to top-down implementation of global governmental policy, whereas Population Health covers everything from large for-profit publicly traded companies to the tiniest solo-practice pediatrician. In fairness to the speaker (and in a kind of peace offering for what is to come) I do think his choice of a label is spot on. The rest of his thesis and its development? Not so much.

There is literally nothing new in the entire exposition. How can you call anything v1.0, the first iteration of something that is truly new, if everything that is used as an example is simply today’s version of yesterday’s news. Let’s start with his primary assertion, that there is a new move afoot in which healthcare is only now being provided in the outpatient, rather than the inpatient, setting. This can’t be a doctor who is taking care of any patients in the real world. It is long been the exception rather than the rule that a majority of surgeries take place in an outpatient setting. Heck, 99.9% of eye surgeries have occurred in this setting since the 1980’s. So, too, for invasive testing like colonoscopy, bronchoscopy and cardiac catheterizations of all kinds. It would be much more accurate to state that we are in the end game phase of this transition, v10.0 if you will. For crying out loud, this is such a mature part of the evolution of healthcare in America that any essence of patient-centered care that would require an admission to a hospital is dismissed outright, one more nail in the coffin of that now meaningless label.

How about the assertion that we are only now engaging in a concerted effort to improve the health of our population as opposed to simply treating various maladies? This one kills me. Really? All of a sudden the entire healthcare/government/industry axis is only now finally seeking to improve the general health of our people by preventing illness? Now, in 2016, we have population health v1.0?! That’s laughable. If our young scholar is anything like yours truly, the last stop he made before making his way to the lectern was the loo. HeLOOOoh. Indoor plumbing anyone? You can make a sincere argument that v1.0 of population health efforts occurred a hundred hears ago with the introduction of the kitchen sink and the toilet.

If we confine our discussion to matters more purely medical any reasonable view must acknowledge the tremendous life-saving effect of mass vaccinations for childhood illnesses. Smallpox, polio, and measles each killed hundreds of thousands every year before the advent of widespread vaccination programs. Even efforts which we would now condemn like the sequestration of TB patients in sanitariums must be considered a type of population health program. Despite our modern day fetish with privacy issues, the near elimination of syphilis  in the Western world through mandatory case reporting and contact notification cannot be forgotten or ignored.

When we talk of Population Health in this day and age we are typically talking about mitigating the effects of modern society. Indeed, in cases such as nutrition, we are actually talking about undoing the adverse effects of prior Population Health efforts. The U.S. government either simply got it wrong, or was led awry by a cynical effort by food producers who surreptitiously funded self-serving research. No matter. We are now in possession of a sedentary, overweight population susceptible to once less common diseases that now run rampant. There is little argument that the healthcare community should engage in the effort to keep people healthy as well as treat them when they are not. The notion that this is something truly new is a fanciful notion bred of what must be purposeful historical ignorance.

So, Population Health v1.0? Hardly. A process that arguably began with the invention of the flush toilet cannot be labeled new, no matter how good this makes a speaker, a system sound, or a concept sound. Those who fail to study history may be doomed to repeat it, though in this case there really is no need to do so. Acknowledge the past, make a sincere effort to place your idea in its appropriate slot in that history, and then make a case for your proposal. Have a little humility. There’s nothing wrong with being v10.0. Especially if it works.

You know you have a problem when T’ai chi hurts. Quite a come down for a guy who’s been doing CrossFit for 10+ years to be so uncomfortable that this ancient Chinese exercise causes enough discomfort that I have to sit down. Oh, it’s nothing exotic or even interesting. I have a companion sports hernia to the one that was fixed 16 years ago (note for CrossFit haters: 6 years prior to discovering CrossFit) to go with a couple of inguinal hernias. A quick little visit to Dr. Google reminds me that weakness in the pelvic floor is an inherited trait. I have a very vivid memory of my Dad joining us for a golf boondoggle wearing a monstrous, medieval apparatus called a truss to hold his hernia in while he played. Again, not CrossFit-related, but definitely messing with my CrossFit Rx for health.

It’s really weird being a patient. On the other side of the stethoscope as it were. I’m not under any illusions that my experience is a run-of-the-mill patient experience. After all, I’m a mid-career specialist who is going to have surgery at the hospital where I’ve operated for 25+ years, one that is run by my own internist and good friend. My surgeon was chosen after talking with the surgical assistants who see everyone operate. They told me who THEY would let operate on themselves and their families. My pre-op testing was arranged around my schedule in a way that was most convenient for me, the patient, and not the hospital, surgeon, or system. I picked my surgical date to coincide with a planned 4-day weekend.

Like I said, not your typical experience heading into surgery.

Nonetheless, this whole patient thing is strange. As a surgeon I am accustomed to being in control of any aspect of the surgical process I care to be involved in. Whether to do surgery and what kind of surgery to do are decisions in my hands. My herniacopia surgery? Not so much. I know that my surgeon is planning laparoscopic surgery, and that both inguinal hernias will be fixed for sure. There’s no way to know the extent of their effect on my most pressing symptoms (see what I did there?), but now that I know they are present I am hyper aware of what they are doing to me in addition to my presenting symptoms. Here’s the rub: I am convinced that it is the Spygelian or sports hernia that’s messing with me, but since it is not obvious on my pre-op CT scan my surgeon is not promising that it will be fixed. There are few things more distressing to a surgeon than not being in control of surgery, and despite all of the wonderful advantages I enjoy because of who I am, what I do, and where it’s happening, this side of the stethoscope is distressing.

What’s the big deal, then? He doesn’t see a hernia he feels is worthy of attention and only does the 2 basic, standard issue inguinal hernias. Less surgery is better than more, right? Sure. Of course it is. Unless it’s not, and that’s the big deal. I had discomfort and weakness as a 40 year old due to a Spygelian hernia on the left side. That hernia was diagnosed by a classic old-school general surgeon without any fancy imaging tests. Just an eerily well-placed index finger and a loudly yelped “YES” when he asked me “does it hurt right here?”, and off to the OR. Why he didn’t fix both sides then I’ll never know, because it was only a matter of time until the right shoe dropped.

Although CrossFit did not cause any of these problems it was definitely CrossFit that let me know I had a problem. Not only that, but it is precisely my performance, both degree and detail, that has convinced me that the Spygelian hernia is enough of an issue to fix. We measure everything in CrossFit. Time, weight, reps. We compare our results with previous efforts as a way of evaluating our fitness, and to some degree to monitor the quality of our workout programming. Gradually, over the course of 12 months or so, I have lost the ability to brace and maintain my mid-line with my abdominal muscles. In a classic cascade of calamity my secondary pelvic support muscles–gluteus medeus, piriformis, obturator, and that rat-bastard the extensor fascia lata–took over and eventually began to fail. At first it was just a little discomfort, followed by a little weakness, ending up in constant cramping and pain in all of them. At this time last year I pulled a lifetime PR in the deadlift; this weekend I could barely do reps at bodyweight.

The first place I felt pain was in that tiny little area that old-school doc poked so many years ago.

Meh. Tough spot, for me or any other patient. I’m not bringing unrefereed information from the internet to the game. I had this same thing 16 years ago, and I have objective data from my CrossFit gym that supports my contention. How best to present this to my surgeon? In this regard I am little different than anyone else with pre-op questions. At our initial visit together I laid out my symptoms and my history. During our post-CT phone call I reiterated my concern about not fixing the Spygelian hernia, however small it might be on direct visualization. Not gonna lie, the thought of having the surgery and continuing to have the same issues when I exercise makes me nauseous.

What’ll I do? Well, I guess this is the place where I really am just like everyone else when it comes to being on this side of the stethoscope. I will just have to have confidence in the surgeon I chose that he will do everything that needs to be done to solve my problem. After all, just like anyone else, I’ll be asleep while it’s going on. Kinda tough to have any input right then, ya know? It will be weeks before I will be able to really test out my results, and those weeks will likely be filled with all sorts of exotic physical therapy exercises geared toward strengthening my abs and accessory muscles, and getting my gluteus maximus to start firing again. Turns out my pain in the ass has actually been a pain in the ass…your glutes turn off in response to losing the ability to brace with your abs.

I am SO ready for this to be fixed, and I’m thinking I feel pretty good about how it’s all going to turn out. If not, well, I’m sure I’ll at least be able to enjoy pain free T’ai chi. My surgeon will undoubtedly take my concerns to heart when he is doing my surgery. After all, we will still share the same side of the stethoscope after the surgery is done.

Boy oh boy, was it crowded in the Ambulatory Surgery Center on Tuesday. The place was crawling with techie types in outfits that looked an awful lot like Walmart uniforms, bumping into a cadre of Suits who were there doing…well…I’m not sure what the Suits were doing. They were mostly in the way of productive people doing useful stuff. My day started off with an almost immediate case of miss met expectations as the tech support person who’d promised she would be there to guide me on Day One, since she’d spent so much time personally preparing both me and Epic for our first CPOE date, was nowhere to be found. Sadly, it was apparent that the otherwise quite lovely and very talented woman who was there instead, let’s call her my “Doc Minder”, was going to need some catching up on what had gone before, despite her assurances that she’d been fully prepared by Top Tech, the Doctor Whisperer.

“Dr. White, I was led to believe that all of your pre-op orders have already been entered into the system.” Uh oh. I spent 2 hours the prior Thursday afternoon with the head honcho “Doctor Whisperer” entering all of those orders. My first thought was “why don’t you know this already, since you have access to all of my charts today and could have looked?”, followed by “How is it possible that you didn’t look so that you could head off any problems before I got here?” What I said was: “they’d better be.” Ugh. Was this a sign? Given my state of mind heading into this day you can imagine the kinds of thoughts going through my head when the first mobile computer brought to the OR for my use didn’t work. Like, not at all. Rough start.

Turns out that I have some history with these mobile computers and World Class Hospital. They were originally called “Computers on Wheels”, which I instantly renamed “COWs”. Makes sense, right? Easy. Cute. Man, did that get shot down fast. Something about cultural sensitivity, or, really, I have no idea, but calling them a “COW” was verboten. I’ve been using that “Lipstick on a Pig” analogy when discussing everyone’s sensitivity to my unhappiness about Epic in general and CPOE in particular. My new four-wheeled “Pig” arrived and to my surprise things actually started to look up. The computer worked so well that I found myself calling it “Babe”.

Having all of my pre-op orders already in the system turned out to be a critical step in giving the day a fighting chance to succeed. All of the orders had, indeed, successfully made their way from the chart to the nurses in pre-op, and from there to what seemed to be a fairly regular implementation for my surgical patients. This is important because patient preparation starts well before I arrive in the morning for surgical patients, and begins for lasers while I am toiling away in the OR. The fact that it took some 2 hours to get these orders entered last week (total of 19 cases), a process that had heretofore occurred entirely without needing me to engage, was momentarily lost in the euphoria that I didn’t need to put out any pre-op order fires (hmmm…would that be a Pig roast? Sorry.).

Although this was day one for implementing CPOE in this particular ASC, the fact that the main campus of World Class Hospital, as well as several other WCH ASC’s had already made the transition, meant I really wasn’t truly a guinea pig (too much?). Standard order sets already existed for eye surgery, and it was relatively simple for the behind-the-scenes cave-dwellers to create both order sets specific for our ASC as well as templates for my op notes (more on the cave-dwellers in Part III). As I noted in Part I our turnover time in a single OR for cataract surgery is ~7:00. With some gentle and kind prompting from my “Doc Minder” I was easily able to do everything “Babe” asked of me between cases in addition to my usual duties (chat with the family, etc.). My kindly “DM” agreed that “Babe” would probably slow me down on busier days when I hop between two OR’s, but for today at least there was no time suck for cataract surgery. I even did one fewer dictation because the “Doctor Whisperer” had helped me create a template for “Complex Cataract Surgery”.

I may or may not have said “That’s some Pig!” out loud.

Alas, everyone involved knew that the happiness was fated to be short-lived. The efficiency bar is so high when we do ophthalmic lasers that there was simply no way that “Babe” was going to be able to keep up; he was back to being a Pig as soon he moseyed over to the laserium. Because every patient’s chart must be completed before they are allowed to leave the facility–images of armed guards wearing Google Glass running Epic and manning the exits filled my head–I had to attend to all of “Babe’s” needs before starting with the next patient. This process took 1.5-2X as long as usual, increasing the time it took me to do my lasers and making it a bit less convenient for my patients.

Then everything went off the rails.

Computers are computers, and software is software. They are both heroes or goats depending on how well they fulfill whatever task they are assigned, but they are prisoners of the people who operate them. The plan that all stakeholders had agreed on was for ASC staff to schedule all surgeries booked by SkyVision as of Monday by the time I finished lasers on Tuesday. I would then do all of the pre-op ordering for the following week before leaving for the day. Under the best of circumstances every minute I spend doing this is both a time and a happiness suck for me because, as I noted above, prior to CPOE I didn’t have to do ANY of it. Naturally, more than half of next week’s patients had not yet been entered into the system making it necessary to not only stick around to pet my Pig (I know) but also wait for the overworked WCH staff to complete their tasks. All in all it cost me about an hour, stealing my workout and rushing my lunch so that I could be in the office and start clinic without making my patients wait.

What’s the take-home? Tune in for Part III. For the moment let me just say…that’ll do Pig, that’ll do.

Skyvision Centers has a subsidiary company called the Skyvision Business Lab. We do business process research for pharmaceutical companies, medical device companies, and other medical businesses in the eye care arena. One of the companies we have worked for is a very cool company that produces animated educational videos for  ophthalmologists and optometrists. I had an interesting experience while talking to their chief technology officer. It was interesting because the conversation proved our basic reason for existence at the Business Lab, that it is impossible for any company to develop, sell, and install any kind of product in our world without understanding the ins and outs of every day activities in an eye care practice.

Of course, I always find it extremely interesting when I’m right!

It was a tiny little point, really, but how could you know something as small and seemingly insignificant as our discovery unless you had spent time on the “frontline” of medical practice? The chief technology officer for the video company was frustrated because doctors and their staff were not using this really cool product that they had purchased. Furthermore, because they weren’t using it, they were failing to buy downstream products from the video company. As it turns out the salespeople for this company were telling the doctors that this particular product should be “turned on” by the staff at the front desk of the office. This is exactly the wrong place because the front staff personnel simply have neither the time, nor the understanding, nor any incentive whatsoever to do this. The product actually works beautifully if it is “turned on” by the back-office staff. Bingo! Problem solved.

So what does this have to do with Electronic Medical Records (EMR), and for heaven’s sake what does this have to do with underpants? It’s simple, really. When was the last time you bought a totally new type of underpants, underpants that you had never seen before, and underpants that you had certainly never worn before, without trying them on? Furthermore, what’s the likelihood that you would allow someone else to design, fit, and choose a style  of underpants for you if that someone has not only never met you but has never even seen a picture of you?!  That’s the image I get every time I read an article about EMR.

In theory the concept of an electronic medical record that would allow permanent storage of every bit of medical information, with the ability to share that information between and among doctors and hospitals involved in the patient’s care, is so logical and obvious that debating the point seems silly. If you have ever seen my handwriting, for example, you’d realize that the entire field of EMR was worth developing just to make doctors stop using pens and pencils! Trust me on this… the doctor hasn’t yet been trained who is also a specialist in penmanship.

I actually trained at  two of the pioneering hospitals in the use of electronic medical records, and indeed in the use of computers in medicine in general. Dr. Larry Weed and Dr. Dennis Plante at the University of Vermont were pioneers in the concept of using computing power to make more accurate medical diagnoses. Both the University of Vermont Medical Center and the Maine Medical Center were among the very first institutions to develop and implement digital medical records for the storage and use of clinical data like lab reports and radiology reports. In theory both of these areas make sense, but in practice the storage and display of clinical data is all that’s actually helpful in day-to-day practice.

If this is the case, if the acquisition, storage, and retrieval of critical data is helpful, the next logical step must be to do the same thing with the information obtained in doctor’s offices, right? Well, in theory this makes a ton of sense. The problem is that nearly none of the EMR systems now in place have been designed from the doctor/patient experience outward; they’ve all been designed from the outside in, kind of like someone imagining what kind of underpants you might need or might like to wear, and making a guess about what size would fit you. With a few exceptions, tiny companies that are likely to be steamrolled in the process, every single EMR on the market is the wrong fit for a doctor and a patient.

Why is this? How could this possibly be with all the lip service that is being paid to the doctor /patient relationship and the importance of getting better care to patients? It goes back to that same tiny little problem that the medical video company tripped over: it’s really hard to know how something should work unless you spend some time where the work is going to be done. Electronic medical records in today’s market are responsive to INSTITUTIONS, insurance companies and governments and large hospital systems. System before doctor, doctor before staff, staff before patient. Today’s EMR’s have been designed with two spoken goals in mind: saving money and reducing medical errors. Should be a slamdunk at that, right? But even here the systems bat only .500, producing reams of data that will eventually allow distant institutions to pare medical spending, but neither capturing nor analyzing the correct data to improve both medical outcomes and medical safety. Fail here, too, but that’s another story entirely.

So what’s the solution? Well for me the answer is really pretty easy and pretty obvious. Send the underwear designer into the dressing room! Program design, programs of any type, are one part “knowledge of need” and one part plumbing. How can you know what type of plumbing is necessary unless you go and look at the exact place where the plumbing is needed? How can you know what size and what shape and what style of underwear will fit unless you actually go and look at the person who will be wearing the underwear? It’s so simple and so obvious that it sometimes makes me want to scream. Put the program designers in the offices of doctors who are actually seeing patients. Set them side-by-each. Make them sit next to the patients and experience what it’s like to receive care.

THEN design the program.

I’m available.The  Skyvision Business Lab is available. I have a hunch that the solution will hinge on something as simple and fundamental as my example above — front desk versus back office.  It doesn’t necessarily have to be me, and doesn’t necessarily have to be us, but it absolutely is necessary for it to be doctors and practices like Skyvision Centers, places where doctors and nurses and staff members actually take care of patients. Places where patients go to stay healthy or return to health. Places where it’s patient before staff, staff before doctor, doctor before system.

For whatever it’s worth I’m 5’8″ tall, I weigh 150 pounds, and I’m relatively lean for an old guy. I guess it’s a little embarrassing to admit this… I still wear “TightyWhiteys”, but I’m open-minded. I’m willing to change.

Just take a look at me first before you choose my underpants for me.

The topic of “live to work vs. work to live” has been on the table in one form or another in our house for weeks now.  It’s a moving target for sure. What does it mean at 50+? How has the conversation changed now that Beth and I are living “Empty Nesters 2.0”? The inexorable, constant change that has been forced down the throats of physicians since January of 2009 has totally upended how I feel about my job. Since Beth is now intimately involved in my business she has been drawn into this part of the conversation.

Why? Well, how many folks do you know who have managed to fold together their vocation and their avocation? Their employment and their passion? How many people do you know who give the same answer to the questions “What do you do for a living?” and “What is your hobby?” Not many, eh? In the world of my day job I can name exactly two. Cleveland has been good to me, but the fact remains that I moved to Cleveland solely for the job.

Cleveland has neither ocean nor mountain.

Not every gig is like this of course. It’s quite a bit different in the CrossFit world, for example. One of my very good friends, met through CrossFit, is an attorney who openly calls his day job his dream. You guessed it…he’s CF’s corporate counsel. Work and passion, vocation and avocation all wrapped up into one whole. No real “live to work or work to live” stuff for him, or indeed for most of the 7500+ Affiliate owners like my sons. I’m not entirely sure if they, or Coach Glassman, truly appreciate how monumental this is. I know my friend Dale does.

For the rest of us, though, we must sit down and have a little chat with ourselves. Is there something that makes us truly happy? Is there a place where we have a greater likelihood of achieving that happiness, some locale where it might be more easily attained? Sure, there might be additional responsibilities we must shoulder (support a family, repay an obligation) that complicate the conversation, but that still leaves room for each of us to LIVE. Could you do whatever that is? Could you move wherever “there” is? All of the folks I’ve met in Key West or Park City or San Diego who work at however many whatevers it takes in order to fish, ride, or surf come to mind.

How about me? How am I doing with this work/live thing? Actually, I’m doing better now than at many other points in my life despite the fact that my new business reality is a somewhat lesser version of past realities. I’m really good at what I do, and I accept and fulfill the responsibility of continuing to improve; the people for whom I work, my patients, fare better now than ever before.

But more and more what I do for work is just that…work. My day job is what allows me to do the stuff that is probably a truer indication of who I am, of what makes me tick. I live as fully as I possibly can when I am at work; I’m good at what I do and it’s easier to enjoy something when you do it well. But I work to live. I’m ever at the process of figuring out just what living means.

Must it be thus? Is it somehow my destiny to not share the lives of those for whom live to work is synonymous with work to live? Meh, I dunno. It takes a certain type of courage to make that leap sometimes, whether that leap is to jump back in or jump all the way out.  I have a friend who lives in Del Mar who once asked me “when are you going to leave that dead end job and work with me?” I clearly didn’t have the courage at the time to fully explore that. Now? Who knows? The courageous decision might be just staying where I am, jumping back “in” as it were.

In the end, though, I think it’s important to sit yourself down and have that conversation with yourself. Working to live, or living to work? It’s especially important if who you are and what you do are not both found where you work.

Think of it not so much as a work in progress, but more as a life in progress.

Admit it. How many times have you heard or read a professional athlete utter the words “it’s not about the money” and forced yourself not to gag? Seriously, it’s ALWAYS about the money.

We hear this ad nauseum during the free agent season in every professional team sport as players from superstars on down to less-than-super subs angle for the biggest payday possible. The phrases “max contract”, “salary cap”, and “veteran exception” vie for our attention with batting averages, rebounds, and sacks. We the fans are spectators not only to the games but also to the gamesmanship between owners and players, each trying to maximize their piece of the pie. It’s ALL about the money.

The realist in me wants to acknowledge that this is simply the labor/management battle played out on the front page of the Sports Section. How, I ask, is this any different from the headlines in the Business Section where the “Masters of the Universe” keep score with their multi-billion dollar spoils?

But then it hits me…in the board rooms and the banks how much money you make is the ONLY scorecard. There is no other way to rank the players or the teams. The person with the highest salary wins. That’s it. Nothing else. The company/bank with the highest profit is the “best”. If Goldman Sacs makes more money than JP Morgan then Goldman is the better bank and Lloyd Blankfield is better and smarter than Jamie Dimon. Money is the only metric, and no one sits at home playing Fantasy Wall Street or cheering for their home town Hedge Fund.

And there’s the rub–the games we watch all have a scorecard, and we keep the score of the games the same way whether it’s the Cleveland Browns vs. the Miami Dolphins in the NFL, or the Shaker Heights Eagles vs. the Southbridge Mass Ponies in Pop Warner. A free throw is one point whether it’s Bingo Smith at the line in the NBA or bingo (yours truly) at Tri-City Park in Rocky River. If you’re playing the game in the back yard, or if you’re a fan of the pro game it doesn’t really matter. What you care about is winning. Period.

When was the last time you heard the words “it’s not about the money” from a big-time athlete, spoken or unspoken, and you believed them? I can come up with exactly one, and I’ve been following pro and college sports since I could turn on a TV. I really did believe Tim Tebow, the kid from Florida, who came back for his senior year to play quarterback. I mean, what did he have to gain money-wise by doing that? Heisman trophy winner. Leader of two NCAA champions. Top five pick in the draft whenever he came out. I really think the kid just loves college and being a college student and football player. Other than him? Shut-out.

But there’s something really interesting blowing in the winds of the NBA. You know that place, home to the “Bird Exception” that allowed the Celtics to pay Larry $33 Million in his last season. Where Michael Jordan took home a cool $30 Million despite making somewhere north of $50 Million in endorsements each year for 10 + years. Some upper mid-level power forward–I can’t even remember his name–agreed to hold off on signing his contract with the Cleveland Cavaliers, promised a huge raise and the chance to play with LeBron James, only to exile himself to Utah when an offer of more money arose. I DO remember what he said in the paper, though. Yup…you guessed it…”it’s not about the money.”

Still, there it is, a whisper dancing just outside the conversation. Someone, a very important someone, has a chance to utter that fateful phrase, “it’s not about the money”, and really mean it. Here now is LeBron James, a free agent at the end of this NBA season, who has the opportunity to sign a contract that is all about his team winning. LeBron, who makes somewhere in the vicinity of $80 Million in endorsement money, can sign a “max contract” that will pay him around $100 Million or so over 7 years, maximizing his income from playing the game but also maximizing the difficulty that General Manager Danny Ferry will have gathering talent to surround LeBron in order to win. Win like you and I think about winning, as in winning NBA championships.

It’s just the tiniest of breezes now, barely enough to tickle what’s left of the leaves on the trees in Cleveland, not even enough to rustle the top sheet of the Plain Dealer as it sits in your driveway. LeBron could sign for the veteran’s minimum, about $2 Million per year. The $2 Million wouldn’t even count against the Cav’s salary cap! Doing this would free up, what, $20, $25 Million per year? That’s enough to sign not one but TWO major players, especially if they, too, sign on just a little bit to “it’s not about the money”, it’s about playing with LeBron and WINNING. Dwayne Wade AND Chris Bosh in Cleveland with LeBron James. In Cleveland, playing to win.

It’s still about the money, of course. I’m not naive enough to think that there wouldn’t be massive positive PR for LeBron if he took a minimum contract and stayed in his hometown city and then won. I also know that he can revisit his max contract option in 2 or 3 years and get pretty much the same number he would get now, even with the massive increase in off-court income likely to come his way if he played it my way. But still, a chance to say “it’s not about the money” and really mean it, even if it’s only for a couple of years? It’s man bites dog stuff.

Who knows if it will happen but I get a little smile as I think about the hurricane that will tear through the Player’s association if LeBron does this. I love thinking about David Stern’s office after the tornado plows through if LeBron comes out and says “it’s not about the money” and means it. If LeBron James is the first professional athlete in modern sports history who literally puts his money where his mouth is.

Hey…anybody out there have Maverick Carter’s cell number?