Random Thoughts from a Restless Mind

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

I’m calling it Bullshit.

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

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

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

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

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

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

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

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.