Random Thoughts from a Restless Mind

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.

The endless debates about the “Pay Gap” between men and women in the United States drones on. Today is “Equal Pay Day”, kinda like “Tax Day”, the day when you stop paying the government and instead start paying yourself, only it’s the day when the “average” woman supposedly has to wait for before she starts to make what a man makes. It all makes for great spectacle and epic barstool arguments for the same reason that people argue about who’s greater, Michael or Elgin, Kareem or Russell, The Babe or Barry: there is no proper, standard way to measure the issue at hand. On a barstool arguing “greatest ever” you never agree on either the definition of “greatest”, nor can you account for the vast differences in historical eras.

So it is with the pay gap. No one agrees on what constitutes work, let alone equal work.

This creates the maddening situation in which we find ourselves now whenever this comes up for discussion. Absent a meaningful definition of either “work” or “equal” we are left with folks on all possible sides of the issue simply choosing whatever statistic will support their deeply held beliefs about the issue. It’s crazy, actually. I read a dozen citations today and each one was so deeply flawed that it couldn’t stand the scrutiny of the middle if you velcroed it to the  50 yard line. Work is invariably conflated with “hours worked” with no discernible effort made to investigate something like intensity, or the measurable work performed per unit of time. “Equal” work is just a quagmire of competing opinions with, again, no effort whatsoever at objective measurement. How can you have a discussion that is meant to conclude with some sort of actionable agreement when all you do is pull numbers out of the ether and throw them at each other?

While engaging in a sorta, kinda conversation about this on Twitter it struck me that I actually live and work in the perfect laboratory to investigate the issue of the Pay Gap between men and women. You see, we have reams of objective data that can be evaluated. We all, men and women, do exactly the same things if we have the same jobs. Not only that but we have a unit of measurement for that work, the RVU. If Dr. Darrell does a cataract surgery and Dr. Dora does a cataract surgery, we have both done the same job. We can even determine the “intensity” of our work, our output if you will. A simple survey of hours worked per day can generate the metric: RVU/hour. Better yet, don’t take my word for it in a survey, just look at that heretofore meaningless and useless EMR and look at the measured time Darrell and Dora took to do their work. The OR record is a precise measurement of how much work we did per unit of time.

This is powerful stuff. Work is defined. An appendectomy is an appendectomy. A Level 4 New Patient Office Encounter is a Level 4…you get the idea. You get to compare apples to apples, heck, you get to compare Honeycrisp apples to Honeycrisp apples. It doesn’t matter if you are a man or woman or transgender. White, Black, Brown, Yellow, Red (did I miss anyone?), Millennial, Boomer and everything in between, work is work and an RVU is an RVU. Heck, you could gather all of the information about the work without anyone knowing who did it until after it’s all together. We could have a big unveiling when we lift the blinders and see who did what and how much they did. Seriously, how cool is this? It would almost be like science.

Let’s do be a bit serious for a moment. Imagine what kind of information we could acquire and what kinds of questions we could ask and answer. For sure there will be very reasonable concerns about how much we will be able to extrapolate from medicine to other areas of employment (advertising, investment banking, etc.), but it’s a great place to start. The question of the Gender Gap is primary, but how about looking at work across the generations. There is a “feeling” in medicine, certainly among crusty old folks in my generation, that younger physicians of both genders work fewer hours and do less work per hour when they do work. Is that true? It sure looks like it would be easy to answer that one, too.

There are actually a number of other issues in medicine that would be clarified if we had this kind of data, at least insofar as the work done is concerned. For example, how do private practitioners stack up against salaried physicians in large groups? Is there a correlation between how those salaries are determined and the intensity of work done? We can also look at value, work done per dollar paid (again, assuming equal outcomes). Where are we getting the best bang for our buck? For that matter, with the EMR’s that never sleep we can actually look at the responsiveness of doctors to their patients in urgent or emergent circumstances. Is there one group (men vs. women, private practice vs. employed) who are more responsive?

Having a discussion that is based on hard definitions of terms and data-driven rather than belief-driven opens up a whole world of meaningful inquiry.

Once upon a time I was among the highest paid physicians in the U.S. I worked insane hours, and the intensity of my hourly output was off the charts. In a word, I earned every penny I made, and the fact that I made more than another ophthalmologist had nothing to do with the fact that I was a man. Funny thing though–I now make a fraction of what I once made because I don’t work as much as I once did. The intensity of my work is similar; I still do as much work per unit of time, and my ability to perform at this high level of intensity is still greater than 95% of my peers, I just work fewer hours. What are we to say about women who do what I do, work more hours than I do, and yet do less work? Is there a gender gap in pay if I make more money than they do? What are we to say about my ambitious female colleagues who work more hours than I and work at the same intensity? I’m firmly stating that they should make more than I do. Is that the reality on the ground?

In medicine we have the ability to answer this question in a very objective, non-ideological way. I don’t know if what we find will be something we can extrapolate to other jobs, especially if we find that pay is directly related to actual work done in a domain where work can be both defined and measured. But hey, it’s a start. And it’s way better than just playing emotional whack-a-mole with how we value what we all do.

It’s my own fault, really. I admit that I had allowed myself to believe that the uneasy peace I’d made with Epic, the EMR utilized at World Class Hospital, would be a lasting one. A peace for all time. I would interact with the beast on a quarterly basis, signing verbal orders that kindly nurses had accepted and op notes for surgeries that deviated just enough from the routine that they needed to be dictated fresh. In return I would be allowed to simply sign orders, op notes, and other sundry paperwork as I had been doing for the last 24 years. Simple. Everyone wins. My OR days run efficiently saving me, my patients, and the institution countless hours of wasted time, and I continue to bring the majority of my cases to one of the outpatient surgery centers owned by World Class Hospital. (It should be noted that I am the lowest cost eye surgeon in the entire system, thereby generating the greatest per/case profit for WCH). I truly believed that I would still find sanctuary in the OR from the thousands of chickens pecking away at my professional satisfaction and by extension my general degree of happiness.

BzzzzzzPfffffTttttt…sorry Doc, that’s the wrong answer. Johnny, tell our contestant about his lovely parting gifts.

For the first 16 or so years of my post-residency career literally every process change in which I’ve been involved has had a direct, positive effect on outcomes or safety, patient experience, or my efficiency. About 8 years ago tiny little negative things started to creep in, some of which chipped away at that efficiency. A few more forms to sign. More pre-op checkpoints for my patients to pass on their way to the OR. Along with this came the madness that arises when a huge organization plays defense against an unregulated regulator like CMS (medicare) or JCHO (the hospital regulator). Not one, not two, but three personal checks by the surgeon to confirm the surgical site. A pharmacy either running scared or run amok that demanded a brand new bottle of eye drops for every laser patient despite an industry-wide infection rate on lasers of 0.00000001%. It was mostly piddly-diddly stuff, and the OR staff did their very best to run interference and preserve our efficiency.

Now? Oh man. The introduction of the Epic EMR into the OR has turned our 2-nurse room into a 2.5-3 nurse set-up. There is so much dropping down and clicking necessary to fulfill the beast’s demands (man, would this analogy be perfect if they still let us call them Computers On Wheels?! Feed the COW!). Previously, one circulator could do all of the paperwork, prep the patient, and have time to spare to facilitate room turnover. Admittedly I move pretty quickly as I do cataract surgery, but it’s impossible for just one person to do all of these tasks now that Epic must be served, without all of the rest of us sitting on our hands and waiting. The local administration and the staff have rallied around me and my patients and for most cases an extra pair of hands is there to keep things moving. Heck, I do my part as well by taking the trash out of the room and bringing the used instruments back to the sterilization room.

With the introduction and implementation of CPOE (Computerized Physician Order Entry) all of our efforts to improve efficiency, with all of the wonderful things efficiency brings, will be for naught.

How can I possibly know this before experiencing it even once? People talk, and doctors are people. I’ve chatted with a score of surgeons about how long it takes for them to do what Epic and World Class Hospital requires of them, and I’ve got a bit of experience just signing stuff after the fact. It just simply takes a lot of time. Add to that an institutional indifference to the psychological effect of hoovering  time out of a surgeon’s day and you’ve created the world’s biggest, most frightening chicken peck.

Tell you what, let me share a few numbers with you before we make the switch, memorializing them here, dated, before the transition, so that there’s no possibility that I made stuff up after the fact. The baseline numbers I am about to share admittedly are rosy in part because everything that can be done to/with the paperwork by someone NOT me happens as part of well-established routine. Details such as start/stop times, IOL serial numbers, etc. are filled in by support staff; there is little to no chance that this will be the case when everything moves from paper to screen judging by other surgeon’s experiences.

95+% of my cases are either cataract surgeries, post-cataract lasers, or lasers to treat dangerously narrow anterior chamber angles. Through a combination of fortunate genetics and hard work I have become very good, and very fast, at all of these procedures. My team and I achieve enviable outcomes and microscopic complication rates despite the fact that we move very, very quickly. A patient having cataract surgery spends approximately 15 minutes in the OR. For comparison sake, a study from a prestigious eye hospital recently posted an average time in room of ~33 minutes for its top three cataract surgeons. Turn-over time (patient out/next patient in) is 6-7 minutes. On average it takes me 26 seconds to complete ALL of the paperwork that must be done in the OR. It takes another 9 seconds to sign the op note when it is returned from transcription; this is important because Epic will require either finding, editing, and signing an op note in the OR, or dictating one on the spot.

Our team of nurses and doctor has achieved an even more enviable efficiency when doing lasers. The average time it takes for a patient to have the entire laser experience–enter the laserium, be seated at the laser, have the laser successfully performed, and leave the room–is 3 minutes. That is not a typo. The average set-up in the United States is closer to 15 minutes or more for this procedure. At the conclusion of the laser it takes me on average of 17 seconds to complete all of the paperwork that is required, and again 9 seconds on average to sign the op note when it becomes available.

You’re probably thinking why this is a big deal, aren’t you? That I should stop whining and just get on with it. Here’s the rub: I do lots of these procedures each time I go to the OR. Any additional clerical time must be multiplied by the number of cases done that day, and all of that time will be stolen from my day. When I finish in the OR I then do other stuff that’s pretty important. Sometimes I go back to the office and see patients, patients who may have had to wait a long time for their appointment. On really good days I get to go to my beloved CrossFit gym to get a workout in. An even better day is one on which I get my WOD in and then sit down in front of the computer to write. These latter things, especially, make me happy. They make it worthwhile to work as hard as I do. Every extra minute it takes me to do something I already have to do not only brings frustration in the OR itself but also keeps me from parts of my life that bring me happiness. A happier doctor is generally a more effective doctor.

We are establishing a baseline today, and that baseline includes a certain degree of happiness. What do you think the chances are that CPOE will increase my happiness? Stay tuned for Part II.

8:00 p.m. on a Friday night. An urgent page from Express Scripts. “Approval needed for sleeping medicine, Agnes Jones*. 800–333–4444.” Agnes Jones is a nursing home patient with a brain tumor.

4:59 PM, Friday afternoon. Telephone call from CVS pharmacy. “The nonsteroidal anti-inflammatory eyedrop that you prescribed is not covered by Mrs. Jones’ insurance company. We need your authorization to change to the generic version.” We told Mrs. Jones in writing that the generic version was inferior, caused pain, and had 10 times the complication rate. On Monday.

7:30 AM, Sunday morning. Telephone call from answering service. “Doctor, the prescription that you sent electronically on Tuesday for Mrs. Jones was written incorrectly. Please correct this and refile it immediately. Please remember that your status as a provider is contingent upon meeting our customer service standards.” Confirmation of receipt/prescription filled was received on Wednesday.

And, my very favorite, most recent telephone call, this one from the daughter of one of my patients. “Dr. White, NALC needs you to send them a letter proving that my father’s eye drops are not prescribed for cosmetic purposes.”

Welcome to the world of the American physician in the modern era. There are, of course, a host of entirely appropriate responses to all of these pages, beeps, and phone calls. However, this last one put me over the edge. I sat at my desk with the message in front of me, closed my eyes, and thought about how I’d REALLY like to respond. The totally, truly amazing part about this request to justify the eyedrop prescription was that, not only was all the information necessary to cover this already on file at NALC, and not only did a real, live human being actually look at this file, but she admitted that and gave me her name! Ya can’t make this stuff up.

“Dear Alex:

Thank you for this opportunity to express my thoughts about some of the pitfalls associated with the pending ‘meaningful use’ regulations for computerized health records. After you personally reviewing the record you requested information about eyedrops that I prescribed for one of my patients. There is apparently a concern about whether or not this patient is using said medication for cosmetic rather than medicinal purposes. As you know, among the more significant ‘meaningful uses’ of electronic medical records are to make sure that everyone has the same exact information about a particular patient, to utilize this information in such a way that proper care is ensured, and to be more time-efficient for the patient, doctor, and everyone else involved in the care process.

If you will open up your file again regarding the patient in question, JOSEPH Smith, you’ll see that, had meaningful use activity actually been applied, this entire communication could have been avoided. Had you actually read the file you would have seen that MISTER  Smith is an 87 YEAR OLD MALE with a long-standing diagnosis of GLAUCOMA. As your software no doubt shows, the eyedrop Lumigan  is a first line medical treatment for glaucoma. All of this information is contained in your database since Mr. Smith has been taking this medication for no fewer than five years, and the bill for his office visit was paid in full by NALC, diagnosis: glaucoma.

A copy of this letter will be forwarded to my US Rep. and two senators, the FDA, and CMS along with a note asking how they propose that all of their fancy new laws about EMR and ‘meaningful use’ will prevent lazy and incompetent file clerks from blinding my patients.

I trust that the information in this ‘old–school’ letter is meaningful enough to prove that Mr. Smith’s use of Lumigan is not for cosmetic purposes.

Sincerely,”

——————————————————–

“Dear Alex,

Attachment: Pic.JSmith.jpg

Seriously? Really? You would like me to prove that my toothless, 87-year-old patient named JOSEPH is not using his glaucoma drops for cosmetic purposes?! The guy with the electronic bill in your system with a diagnosis for glaucoma, taking three other glaucoma medicines, all for 20 years? The Joseph Smith who can’t be bothered to remove the 11 skin cancers growing out of his face like barnacles on a sun-scorched barge? COSMETIC?

This is a joke, right?

Sincerely,”

——————————————————————-

” Dear Alex,

You caught me! But please, don’t tell anyone else. We have the largest population of semi retired 87-year-old drag queens in America in our practice. They just can’t let it go! We have been prescribing medicines so that they could maintain their long, luxurious eyelashes forEVER. I mean, who WOULDN’T rather have long, thick, natural lashes, especially after a lifetime fussing with those falsies and all that icky, sticky glue. Joe has been SO happy!

It’s amazing how important it is for him and all the ‘girls’ to be able to bat their eyelashes at those cute boy orderlies in the nursing home.

Not that there’s anything wrong with that…

Sincerely,”

Sigh…

*All names are fictitious, of course. The examples are not.