Random Thoughts from a Restless Mind

Here is the direct link to my “anything goes” podcast on eyecare. In this episode I introduce the background behind EMR and computers in medicine in general.

https://www.healio.com/ophthalmology/podcasts/eye-care-out-loud/episode-7

Copy and past into your browser, at least until I figure out how to put a hyperlink into this blog!

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How perfect is that?

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

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

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

It was like jogging in quicksand.

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

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

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

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

Remember, your SOAP has been replace by APOS.

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

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

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

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

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

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

That’s an awfully tough pill to swallow.

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

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

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

Check that. A million clicks.

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

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

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

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

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.

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?

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.

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…

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…