Random Thoughts from a Restless Mind

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)