Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Posts Tagged ‘ehr’

Tone Across the Service Line

Ever listen to how people address folks on the providing side of the customer service continuum? Do you ever stop to listen to yourself, or think about how you will sound before you speak? Fascinating. In North America we are moving ever more swiftly to an economy that is majority a service economy; we don’t really make stuff so much anymore, we help people use stuff someone else made, or provide assistance based on a knowledge base or skill set. Listening to people on the receive side of the equation is fascinating.

We have been forced to change our EMR at SkyVision. Our office is running behind schedule because of this. My ears are on high alert for how our patients are reacting. I’m prompted to this line of thought by three interactions in the office that happened while I was loitering at the reception desk. Three individuals not so much requesting a service but demanding it, doing so with a tone that implies not only a deep sense of entitlement but also a deeper lack of regard for the individual who will provide that service. Both in tone and content the to-be-served make it clear to the service provider that he or she is there to serve only them. In fact, the servers only reason to exist is to serve, as if the to-be-served were some kind of different, superior version of the species. It’s loathsome, actually.

I spend every waking moment of each working day on the “serve” side of the equation, whether I am a SkyVision plying my profession or CFB coaching. Having achieved some measure of expertise in both it’s very rare that I am on the receiving end of this type of behavior, but it does happen. More often is the case that it is someone lower on the org chart who gets this. The receptionist, phone operator, or check-out person who gets this “lower life-form” treatment, not the doctor or business owner.

Life can be hard for these front line people in a service business. There’s not only a “customer is always right” mentality on the other side of the interaction but also a sense that being a customer who will get what they want is as much as human right as Life or Liberty. That’s what it sounds like, anyway, if you are off to the side listening. No matter how frustrated one might become from a service situation gone wrong it’s important to remember that there is no continuum in the relationship when it comes to the inalienable rights, nor is there any evolutionary hierarchy across that desk or over that phone line.

Danny Meyer, the great NYC restauranteur, is probably closest to correct when he says “the customer is not right all of the time, but mostly right most of the time. A customer [only] has the right to be heard.” How you express yourself when you are on the “receive” side of the customer service experience is not only an important measurement of how you value the person across from you providing the service, but frankly is probably also a predictor for how likely you are to be successful in being heard. It’s instructive that none of the three SkyVision clients who made difficult (bordering on unreasonable) requests in an unpleasant manner were accommodated because doing so would have required an extraordinary effort which may not have been successful in any event.

Sorry, no pithy statement to wrap it up this week. In the end we all want what we want, and we all need to be heard. It helps to look at the person on the other end of the service divide as if you were looking in a mirror. Would you say that, like that, to the person in the reflection?

Sunday musings: Opiate Overdoses and American Health

To the victors go the spoils. History is written by the victors. Truer words, eh?

I find myself turning off all manner of information outlets of late because they are all just so many repeats. The other side of that victor coin is that the vanquished simply repeat the lines of the victor when s/he was losing. Look no further than the kerfuffle about the Accountable Care Act. If you remove time stamps and the naming of characters what one hears or reads is essentially unchanged today from what was said or written some 7 years ago.

Try it.

My sense of ennui is so strong that it is fairly paralyzing. Is there no one out there who is willing or able to propose something that is truly new? Can we not even even come up with new or original complaints and criticisms? Must we be doomed to this endless cycle of sameness about seemingly everything?

It’s almost as if the vanquished do not so much fail to learn from history but that they work very hard to faithfully replay history in exquisite detail, dooming us all.

We are looking at a true health crisis in the U.S. In 2016 some 40,000 Americans died from opiate overdoses. This is more than the number of deaths by firearms by a factor of 4, and is similar to the number of deaths in automobile accidents. This morning I read a startling statistic: 7 million working age men are out of the employment market, and 1/2 of them take painkillers on a daily basis. Crazy, huh?

On CrossFit.com we agree that there is a general crisis of health in the American populace stemming from over-consumption of calories (most of which are high glycemic index carbs) and under-consumption of physical activity. Another equally startling story in this week’s news is the growing acceptance of excess body weight fat as some kind of new normal, a normal that should somehow be institutionalized.Total capitulation, that.  In this discussion one must add the over-consumption of alcohol, because countless studies have shown that this legal substance is responsible for all kinds of negative health effects, both direct and indirect. (As an aside, it does give one pause when one considers the possibility of legalizing another neuro-depressant, marijuana). As if this isn’t enough, we now must add to this toxic recipe the ingestion by any route of opiates.

The U.S. is regularly taken to task for its failure to sit at the top of the world’s life expectancy leader board despite spending the largest amount per capita on healthcare in the world. This criticism becomes more and more unreasonable as we dive further into what it is that actually drives statistics such as life expectancy. Deaths from overdoses are illustrative of the folly of conflating health and healthcare: there is nothing in the healthcare system of treatment that drives this statistic, and the death of these primarily young people has a disproportionate effect on the life expectancy statistic in which it is years lived that we are counting (and losing).

What, then, is to be done, especially in the setting here of health-conscious individuals? It behooves each of us to take a bit of personal responsibility in the discussion and pledge that we will utilize accurate nomenclature, and in turn demand that everyone else in the conversation do likewise. Health and healthcare are not synonyms. Likewise, healthcare and health insurance (itself somewhat of a misnomer) are not the same; one does not lose healthcare when one does not have health insurance, and for certain the ownership of a health insurance policy does not guarantee one access to healthcare. Indeed, because the outcome was inconvenient to the majority of entrenched healthcare interests, the landmark study of Oregon Medicaid recipients that showed no improvement in health outcomes in those with Medicaid compared with those without has been mostly ignored and purposely forgotten. We need to engage in this conversation, but do so with strict fidelity to meaningful terms.

From there we should lead in whatever way we can. This effort is not at all about the treatment of disease, at least not as far as we here are concerned, but rather one of Public Health. There are quite specific areas to be addressed if we wish to effect change. Each area must be subjected to a root cause analysis. Over-consumption of low-quality carbs is near and dear to CrossFit, Inc., and the battle against “Big Soda’s” influence has been engaged. Other influences such as agricultural subsidies should have a similar bright light shined in their direction. How is it that the dramatic reduction of drinking and driving has failed to render deaths from drunken driving a statistical anomaly? Perhaps someone can convince one of those know-better do-gooder billionaires globe-trotting in search of a trendy problem to throw money at to look a bit closer to home when they apply their famous intellect to new thinking about old problems.

As to the tragedy that is opiate overdose deaths, can we please have someone with no skin in the game be given no-risk access to any and all applicable data and just turn them loose? Some guy did a deep dive into the issue of scrubbing the internet of all vestiges of child pornography using a combination of massive computing power and an outsider’s view. Give someone like that the ability to examine the entire opiate ecosystem to uncover some of the hows and whys so that we can make some decisions of the whats of our response with more than just our typical SOP of some self-designated, conflict-of-interest-infected expert who declares that his/her solution should work because of what they are sure must be going on. This seems to be a new thing, after all, and rather young, too. Prior opiate societal infestations surely share some aspects with our present crisis, but I don’t recall the opium dens in the days of the Crusades so routinely offing their customers.

Anything that can be measured can be analyzed. Anything that can be analyzed can be altered utilizing the results of that analysis. What is needed is the double-edged sword of courage to uncover an unpleasant truth, and strength to set aside all manner of short-term personal gain in favor of a long-term solution for societal benefit.

We ought not let 40,000 lives representing hundreds of thousands of years not lived to be lost in vain.

CPOE, An Epic Misadventure: Update

It was the missed workouts that finally got me. That, and the fact that I was not getting to the gym after surgery because I had to RE-DO orders I’d already entered. That caused me to crack. Why I was missing workouts.

Computer Physician Order Entry went live in December at one of the surgery centers where I operate. As is my lifelong pattern, once I decided that I would remain “in the game” at that particular center I simply viewed CPOE as a new set of rules to learn, a new challenge to conquer (however involuntarily), a new game to win. Maybe it’s my first-born status, or perhaps just the result of an upbringing where everything was a contest to be won, but I learned the ins and outs of the system in less than a month. My office staff, the surgery center staff, and I then went about the task of generating a process that would minimize the depth of the “time sink” into which CPOE had tossed me. On days when I was only operating out of one OR I was only down about 2:00 for every laser done and pretty much dormie on the rest of the cases because I could enter orders during pre-existing “dead air” time.

A funny thing happened on the way to happily ever after: patients we knew were scheduled were failing to show up on the OR schedule in time for me to enter their orders, and orders I’d entered started to turn up missing. That’s right…I had sucked it up, learned the system and taken my paddling like a good plebe, and the system insisted on inflicting this random form of unearned pain. The first time it happened I just re-did the orders. The second time I went off. My “Doc Whisperer” watched me put in every order for this coming week, documenting my status as a quick and accurate little Dr. Lemming. Patient lists and screen shots document my every order. All of this is to no avail. Once again, orders I placed for cases to be done tomorrow do not exist in any part of the Epic wasteland that is the EMR at World Class Hospital.

Is anybody paying attention to this? Does anybody care?!

Not only have I been forced to take time out of my day to do something I did not need to do previously, to perform acts of documentation that once took me a fraction of the time it now takes electronically, but these impositions are now compounded by the fact that work I’ve done is nowhere to be found. Lost in the ether, in a world that no longer even uses ether. This is maddening. Is there even a “Happy enough, ever after” with EMR?

Sadly, I’m afraid this is to be continued…

CPOE: Another Epic Misadventure III Post-Mortem

With the launch of SkyVision Centers 10 years ago I entered the era of EMR. Our group was certainly an early adopter, but since we had chosen this path so early we were able to make our own determinations about what we valued in the technology, and what we would not be willing to give up or compromise in order to have EMR. Our choice of platforms was one that expressly sought to enhance the efficiency of a busy specialist, while at the same time allowing us to hold on to a very personal approach to the doctor/patient interaction. That experience has informed my reaction to all subsequent encounters I have had with other EMR’s, government regulations, and the like. The launch of  Epic CPOE at my World Class Hospital ASC was just the latest example.

A tip of the hat and heartfelt thanks to the folks at the ASC who took such a personal interest in my experience. To my surprise and near delight, the CPOE intrusion in the OR during cataract surgery (in a single room) was negligible. There’s a lesson here for implementing EMR changes: do your homework. The reason my day went so smoothly in the OR is that the people who were thinking about me spent the time necessary to head off problems BEFORE I showed up that day. Two sessions with me, both of which occurred AFTER examining my pre-CPOE processes and paperwork, helped to head off predictable and preventable frustrations.

Having said that, a pox on the houses of all who created the tragedy that is the post 2008 EMR. That means both the government “know-betters” who shower all of us in the trenches with dictums on how it’s supposed to be, as well as the EMR software engineers and execs. Never mind that not a one of them could possibly have ever manned a bedpan, let alone a needle-driver, the arrogance of simply declaring what should be without looking at what is continues to be appalling. To a person every single one of my patients complained about being ignored by the ASC staff on CPOE Day One. Heck, there was literally no way for me to position my Pig, “Babe”, so that I could have eye contact with my patients when they entered the laser room; I was just like every other physician lemming with his eyes glued to a screen when they walked in. I at least have 10 years of goodwill built up with my patients so that I might be forgiven for the insult delivered by Epic.

While I’m at it, can we talk about the arrogance of the programming…ahem…experts, the Cave Dwellers at World Class Hospital? Do they work for Epic, World Class Hospital, or some outside agency? I asked for an order set for a particular type of procedure, one that would more exactly represent what and how we do it at our ASC. I was told in no uncertain terms that the Cave Dwellers had already declared that they had done more than enough for me and us, and that I should feel very lucky that they did as much as they had. Seriously. Never mind that my request would have saved me time, saved the staff time, and made for a better experience for the patient. The Cave Dwellers had spoken. These people have as much power to inflict unnecessary pain on productive folks like doctors and nurses as the pharmacists at World Class Hospital (remember a brand new bottle of eyedrops for every patient for every laser to avoid infections that had never happened in the history of laser surgery?). Here’s hoping one of the Cave Dwellers doesn’t recognize some very important name and drops that same load of attitude on that Very Important Person. Kinda makes a lie of the whole “support” part of “tech support”. This is fixable, by the way, if anyone’s listening, especially if they work for World Class Hospital.

In the end there remain two very critical problems with CPOE in general, and EMRs of the Epic ilk in particular. The first and most problematic is that at their heart they are not medical records at all, they are billing and compliance systems. The primary customer is not the physician or the patient but an accountant, and the outcome that is maximized is not a medical outcome but a financial one. These systems will always be a time suck for both doctor and patient (and nurse, and receptionist, and…), and with that will come an inevitable happiness suck. I had a full hour stolen from my day; this isn’t going to get any better. Every one of my patients had an unsatisfactory experience as ASC staff paid more attention to their Pigs than to my patients; this isn’t going to get any better, either.

The second issue reflects the end of my first day with “Babe” and it is the only issue that could possibly get better: computers and software of any sort are only as good as the people using them. Despite all of our planning, all of the preparation that happened before I arrived at the ASC, everything came to a screeching halt when I tried to plug in my orders for next week. The poor woman whose job it was to enter the patients into the system was simply overwhelmed with work. On top of her regular job and her regular duties she was now not only responsible for the additional task of putting patients into the Pig Pen, but she also had a very hard deadline to beat. At the moment of truth it was her failure, but just as it isn’t the waitress who is at fault when she delivers the overcooked steak, neither was it the poor clerk’s fault that I sat and stewed while she completed her task under the baleful glare of her boss. Just as it is the chef who is at fault for the burnt steak, so too is it the fault of management upstream for failing to give a frontline worker the time necessary to feed the Pigs.

Here, at last, is hope. Faint hope, but hope nonetheless. Someone, somewhere in the chain of command at World Class Hospital may realize that they can make this whole CPOE mess a little bit better for at least some of the folks who are affected by it. It won’t be me, or anyone like me; it’s clear that physicians are just interchangeable cogs in this machine–the noisy ones will be replaced. It surely won’t be patients; that ship left port way before Epic arrived, no matter how many ads World Class Hospital takes out declaring fealty to “patient-centered care”. My hope, and my new crusade, is that the non-physicians on the front line who are taking a beating from this will be acknowledged and given the resources necessary to NOT be the fly in the oink-ment (couldn’t resist). They don’t deserve to end up in the crosshairs of a doc looking for a place to put his unhappiness.

Now, the Cave Dwellers on the other hand…

 

Another Epic Misadventure II: CPOE Goes Live

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.

Another Epic Misadventure: Interlude

It’s really quite flattering, all the attention. The cynic would say that it’s all really just an attempt to keep my business, and I’m sure there’s a bit of that going on. After all, even though my surgical volume is down since my I left my original practice to start SkyVision, I still do a rather high volume of surgery at a very low cost/case. Still, the sheer number of folks, not to mention who they are, who have gone out of their way to try to make my CPOE transition go smoothly is impossible to ignore. Folks really do seem to be sincerely concerned about me as a person, someone they know and have come to like enough over many years, not just a surgeon bringing business. If only it wasn’t all so…so…useless.

I know, I know, I sound a bit petulant, but I’ve watched this movie before. I know how it ends. It may sound somewhat ungrateful, what with the head of physician training, Chief of Surgery, and Head of Outpatient Surgery and local administrator among those taking an open interest in my journey. It’s just that the story only ends one way, with a great big time suck that undoes a decade and a half of ever increasing efficiency (and with it patient satisfaction) and the associated assault on my emotional well-being.

All these people walking around with lipstick thinking…hoping…maybe just one more coat and he’ll smile when the pig kisses him.

 

CPOE: Another Epic Misadventure Begins I

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.

 

EMR and Underpants, Still

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.

Why No Real Innovation In EMR?

Apple just released a smaller Tablet, the iPad Mini, and was razzed by the cognoscenti because it broke no new ground. “Reactive.” “The first  time Apple plays defense.” “Nothing to see here, people. We’re walking…we’re walking.” While the Apple Fan Boys (and Girls) were lining up to add to their Apple quivers, the rest of the consumer world reacted with a communal shrug. Why? No real innovation, and that was a surprise in the world of consumer electronics recently dominated by Apple’s serial innovation.

It makes you wonder a bit, doesn’t it, why there’s so little innovation in the world of medicine when it comes to the storage and transfer of information. With all of the cool stuff already available (voice recognition, “pens” that convert script to text, intuitive “next step” software), why do we have such stodgy, clunky software attached to yesterday’s hardware in all of our EMR choices? For heaven’s sake, we don’t even have a universal platform upon which the various and sundry products are built, and so we continue to have interoperability issues more than 10 years after folks started putting this stuff into play. Why is that?

Every computer product I’ve bought and used over the last 10 years has been easier to use than the one it replaced. Each one has allowed me to do more, and usually with a smaller and less expensive gadget. I know it’s a cliche by now, but my phone has more computing power than the first SERVER I bought to run an entire medical business. For $400. I can talk to it, order it to do stuff, and get all kinds of help I never needed faster than I could realize I needed it, and it fits in my pocket. Yet in a medical office state of the art consists of serial drop-downs and mandatory field entries that may or may not include anything germane to my patient. Able to chat with my cell phone through a bluetooth headset, my EMR demands my full, undivided attention, with gaze fixated on screen.

How come?

In the world of consumer electronics the game is all about predicting what the next, big “gotta have it” gadget or service will be. The most exciting and successful products almost invariably carve out new territory and then go on to viral-like growth because they fulfill a need. This kind of technological progress is so powerful that the people who buy this stuff abandon perfectly functional gadgets that do everything one needs or wants in favor of that next, new-better gadget. This phenomenon in turn drives the makers of consumer electronics to create, to innovate. But not in medicine.

Why is this so?

The so-called “market” for EMR is simply non-existent. The power of innovation, either in response to consumers established, stated needs and desires or in anticipation that something new and better will simply take off in the marketplace is non-existent. The kinds of companies that seemingly come out of nowhere were bludgeoned by government mandated requirements that tiny, bootstrap companies just couldn’t fund the effort. Big companies that innovate like a tiny start-up and create whole, new categories, like Apple, simply didn’t. They all just doubled down on old tech and old ideas, an entire industry making iPad mini’s and calling it progress. The perceived danger of innovating and then having a revolutionary product found to lack “meaningful use” stifled the entire industry. Innovation in EMR was DOA.

And now? Now we have the largest medical institutions in the country abandoning their own efforts at software development and marching like lemmings to the Epic sea. The real-world analogy would be the government saying that you could create any type of gadget you could think of to listen to music, but you can only sell record players and vinyl albums on which you must listen to the songs in the exact order in which they appear on the disc to be assured that the check would clear. Oh, and the doc or nurse could only listen through noise-cancelling headphones that would need to be removed in order to talk to a patient.

It doesn’t have to be like this, of course. All it takes is one company with a little vision and some gumption to find a single big-name player with the courage to see that the status quo is sick. Sure, the vast governmental bureaucracy needs to fix a target and then get out of the way so that something that looks like a real consumer electronic product can emerge. That’s all, really. One product that feels like as “0f course” as the iPod, discovered and purchased by one person who folks watch like TechCrunch, a dispassionate and largely uninterested government standing to the side, idle.

A 7″ computer that could power my company 7 years ago hits the market to a collective yawn? Is it really so much to ask for this type of innovation in EMR?

 

An Epic Adventure: Part Whatever

OK, so maybe this part was my fault. I probably would be a bit better at this Epic thing if I did it more frequently than once every two months. Guilty. The thing is, though, that every little thing Epic asks me to do has either already been done on paper, would go faster if it was done on paper, or both.

It takes two discreet steps to enter the software program, even if you are in a CCF institution and working on a CCF computer; it’s even more complex and takes three steps from the comfort of your own computer. I get the security thing; really, I do. I tried it both ways and failed. Epic failure. Again. So once again I had to call in the cavalry in the guise of the physician support team just to get into the system, finally achieving this milestone event after 3 attempts and a total of 100 minutes of work.

Success, right? I’m in. Nothing to do now but clean up my charts, sign this, attest to that, and away I go. Sure…about that. In the interim between my visits there’d been an upgrade, ostensibly to make using Epic easier. Another 45 minutes of frustration ended up in another phone call and a personal visit by one of the support staff to guide me on my adventure. Kinda like being roped to a mountain guide when you really have no business climbing that particular mountain, except on the mountain you chose to be there.

You’re probably wondering why there was such a big interval between my visits to the “mountain”, and why I chose to continue my Epic adventure now. Both have rather simple answers. I hate everything about this process and this program; I feel oppressed, literally, forced to use a bloated,  inefficient bureaucratic load of “make-work” that adds nothing but time and effort to my day, and so I naturally avoid it for as long as possible. How long? Well, long enough this time that the reason I found myself roped to my guide was the Registered Letter informing me that I’d ignored all of the notifications that I was delinquent in my charting and had therefor “voluntarily resigned” my staff position. Another 30 minutes with my guide and my slate was clean.

How, you might ask, had I possibly allowed myself to “voluntarily resign”? I’ve been a doc for some 25 years; I know the medical staff rules. I’ve been signing charts forever. My address, fax number, and email are all unchanged, and I’ve never missed a notification from the hospital before. Despite my obvious, transparent disgust with Epic and everything it imposes on me, it doesn’t make any sense to let that jeopardize my ability to do surgery at this institution by petulantly ignoring my medical staff requirements. How did this happen?

Easy. All of the notifications were messages only available when you log into Epic.