Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Posts Tagged ‘healthcare’

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.

Population Health v10.0

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.

 

 

 

 

 

Measuring Health Part 1: Rationale, Definitions and Background

In 2010 I had a bit of an epiphany. At the time I was a bit over 4 years into my CrossFit journey. It became painfully obvious that the genius that Greg Glassman had applied to physical fitness–a definition of fitness that invited measurement, and in turn the critical evaluation of the efficacy of different fitness programs–was nowhere to be seen in the fields of health and medicine. Indeed, an informal survey carried out in person by my friend Dr. Kathy Weesner and I made it clear that the majority of physicians couldn’t come up with an actionable definition for health despite the fact that we are charged as professionals with helping our patients become “healthy”.

At around this time Coach Glassman published a theory that health was precisely defined as “fitness over time”. In CrossFit Fitness is work capacity across broad time and modal domains. Fitness over years could be depicted as a 3-dimensional graph with axes time, work, and years. As I thought about his thesis, that a backward looking view of an individual’s fitness as defined by CrossFit was a proxy for health, I found myself with the feeling that the definition was intriguing but incomplete. In response I took it upon myself to develop a broader definition of health, one in which fitness was a primary, but not the sole marker or metric. That April I submitted a draft of my definition of health along with a new, broader base of proposed tests that would generate the data that could be used to measure an individual’s health. Over the years it has become clear that Greg and I are more in agreement than not, but a key CrossFit employee at the time had a fundamental disagreement with my thesis, and consequently the article was rejected by the CrossFit Journal. I published my draft here on Random Thoughts later that year.

For almost 6 years I have been mulling this over, threatening to return to the problem of defining and then measuring health in much the same way that Coach Glassman defined and then measured fitness. The quest was derailed by all of the usual time sinks of mid-life. In a humorous irony, the majority of my real, true free time was consumed by the task of helping my sons run their CrossFit Affiliate gym. It is time, now, for me to finish what I started in 2010 if for no other reason than to establish the provenance of the theory.

In order to effectively address any issue whatsoever it is first necessary to have a clear understanding of the definition of terms that may be important to the discussion. I made a similar statement in one of my earliest posts on the importance of understanding the difference between health, healthcare delivery (medicine), and healthcare finance. Here again I fall back on the genius of Greg Glassman: just as one cannot evaluate either fitness or fitness programs without first defining what it is that you are discussing when you say “fitness”, one must first have a definition of “health” before one can begin to measure it. What exactly is “health”? What does it mean to be healthy?

Let’s return for a moment to the physician survey that Dr. Weesner and I did in early 2010. During face-to-face meetings we asked groups of physician colleagues to give us their definition of “health” or “healthy”. The majority of the answers couldn’t have been less inspiring or more disappointing. Indeed, the most common answer was “I don’t know”! Not very comforting, that. The second most common answer was as anticipated: health is the absence of disease. In our American medical system of “disease care” this is an understandable response, of course, but as the basis for the development of a true measurement of “health” it is obvious on its face that this definition has never translated into any actionable metric. Why? Well for one it fails entirely to take into account the very real importance of “fitness”, the expression of health. More specifically, like fitness as a proxy for health, “absence of disease” also fails to address a key requirement for any measurement of health: there is no forward-looking predictive value to simply stating that you have no disease today.

A measurable, actionable definition of health is one that takes into account the degree that disease is present or absent at any given time. It must address physical fitness; to be without a named disease but to be unable to walk up a flight of stairs should not ever be construed as “healthy”. Of equal importance to these factors, any definition of “health” that will generate a meaningful metric must have a predictive value. Your Health Value should provide some measurement of your future likelihood of being disease free and fit. Our little survey of our physician peers did produce just such definitions. Given these requirements I propose that the following are actionable definitions that can be used in healthcare to create measurements in precisely the same way that Greg Glassman’s definition of fitness is used in that realm:

HEALTH: The state in which no infirmity of any kind suppresses, or has the possibility of suppressing the ability to express the full extant of an individual’s potential capacities.

HEALTHY: Able to perform in all ways at the farthest limits of one’s potential capabilities.

With these definitions we can move on to developing a “health metric”, one that can not only assess our present degree of health, but can also predict to some degree our ability to remain healthy. I believe this metric has three component parts: physical fitness as defined by CrossFit, well-being or emotional health, and a factor that addresses traditional or standard medical factors such as blood pressure, cholesterol, genetics and the like. Furthermore, I predict that these three variables are as evident and as logical for “health” as Coach Glassman’s definition is for fitness.

One can have an otherworldly degree of fitness as defined by CrossFit, but what good is it to have a 500 pound deadlift and the ability to run a 4:00 mile if your physical achievement is driven by self-loathing? By the same token, in addition to having a normal result in every conceivable medical test your countenance is as sunny as an 8 year old on vacation, your disposition so Zen-like that the Dali Lama himself wishes he were as happy and serene, but you can’t walk a mile. This surely cannot equal healthy. You are a world-champion long-distance runner, and yet you drop dead from a heart attack, unaware that you have a cholesterol of 800. Fit for sure, but hardly healthy. Fitness, well being, and modern health metrics all have a role in an actionable Health Measurement. Vigorous debate will be necessary to parse the relative weight given to each of these factors, but as I first proposed and wrote in April 2010,all three are clearly necessary components.

In short order I will offer follow-up posts that delve more deeply into each of these three components. I will include suggestions for what and how to measure them. I will conclude with a re-statement of my proposal for a single measurement of health with my suggestion as to the relative weight of the three variables, hopefully inciting the above-mentioned vigorous debate. By doing so I wish to document the originality and timeline of my proposal, acknowledge the intellectual debt owed to Greg Glassman for inspiring me, and reassert my contention that healthcare cannot reach its fullest potential without first agreeing on both a definition of health and how to measure it.

 

 

 

How You Treat the People Who Serve You

In my day job I work in the ultimate customer service business, medicine. 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 customer service equation is fascinating.

I’m prompted to this line of thought by three interactions at my day job, SkyVision. 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 server’s 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 quite loathsome, actually.

I spend every waking moment of each working day on the “serve” side of the equation, whether I am at SkyVision plying my profession or CrossFit Bingo 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 a 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. Being served if you are the customer is not a right at all, not even one up there with the pursuit of happiness. Server and served both have the right to life, liberty, etc.

In a funny little side note, the more effort I (and my partners and staff) make to be better at the whole customer service thing, the less tolerant I am when I am on the receiving end of poor customer service. Actually, I should be a bit more specific on this point: I am much less tolerant if I am being served by an organization that openly preens about its excellent customer care but won’t deliver. Heaven forbid if I detect a cynical lack of effort, either institutional or on a more personal level, when the expectations that I’ve been led to have are mis-met because of this. The harder we try and the better we get at providing an excellent customer experience at SkyVision the less likely I am to choke down indifferent service or a lack of effort when I’ve been lead to believe (and paid for) something extraordinary. The difference, though, is that I initially engage with the expectation that all I have to do is be polite and kind to those folks charged with taking care of me; my first shot across the bow is not to treat them like serfs.

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. After being treated a some sort of sub-human primate, who would make such an effort?

Sorry, no pithy statement to wrap this up. 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 front of you then?

 

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.

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.

 

Who Talks to People Like That?

“I suppose I’m sorry I missed my appointment on Thursday. So, anyway, here are the ground rules for how this phone call is going to go and how you’re going to give me the appointment I want.”

“I know it’s been two years and the doctor said my son would need glasses for school and that it’s really busy during back to school time. Yah Yah…I get it. I don’t care that everyone with after school appointments called weeks ago. School has started and he needs an appointment RIGHT NOW. I demand to talk to the doctor.”

“What do you MEAN the doctor’s 5:00PM appointments are all filled? I told you she wants new contact lenses RIGHT NOW! 10 AM tomorrow is totally unacceptable. You tell the doctor I’ll be coming in with her in 2 weeks and you can be SURE I’m going to tell the doctor how unacceptable this is.” CLICK

Seriously, who talks to people like this? These are all near exact quotes from established patients calling to make appointments for routine, non-emergent visits. All three had received explicit instructions at the conclusion of their previous visits, and all had been sent recall reminders that it was time to make their next appointment. Remember, we are a very busy eyecare practice with 3 doctors that sees emergency patients on a same-day basis, including nights and weekends. We are not averse to working hard or seeing extra patients, and we counsel our patients that we will sometimes run a bit behind because of this ER visit policy. Philosophically it doesn’t seem right to over-book our schedule, making the conscientious have to wait longer in the office during their visit, in order to accommodate those who make little or no effort to respond to our instructions and reminders.

Let alone those who talk to my staff like these three. Sheesh. Trust me, the tone in their voices was exactly as you’d imagine it as you read it, equal parts incredulous and offended that anyone could possibly not understand how much more important THEY are than everyone else on the schedule. It got me to thinking, though. What would it be like if people talked like this in other walks of life?

For instance, you are the Registrar at, oh, how about Harvard. You pick up the phone and somebody’s Daddy is calling about Econ 101 taught by N. Gregory Mankiw. The class is full. Actually, it’s oversubscribed and there’s a waiting list with 125 kids already on it. The registration deadline was 2 weeks ago, a deadline that the young scholar just blew off and a deadline that Daddy doesn’t even acknowledge. ” You’re not listening to me. I told you that my son will be in that class. He has a spot waiting for him at Goldman Sachs and no one is going to  keep him from getting what he deserves. I demand to speak with Mankiw.” How do you think that turns out for Sonny?

Or how about this? The flight to Chicago is full, and since it’s about an hour before takeoff no more folks are coming off the standby list. Standing at the United desk is a very well-dressed professional addressing the agent. “I suppose I’m sorry that I didn’t make it to the earlier flight I was booked on. Here are the ground rules for how this discussion is going to go, and how you are going to escort me onto this flight.” I can definitely see some sort of escort coming, can’t you?

Imagine what it would be like if you could listen to a call coming to a judge’s bailiff from someone who talked to everyone like my three patients. “Really? I said I needed to get this ticket taken care of right away but I’m only available late in the afternoon. 2 weeks from now is too long to wait. 10 AM tomorrow for court? That’s just unacceptable. Why aren’t there more times at the end of the day? I will be there at 5:00 in two weeks and you can be SURE I will tell the judge what I think of this.” What would you give to see that one play out?

When I hear the way people talk to folks who work in health care it makes me wonder how far they take it. Does it go so far as to extend to Church? “Listen Father, it’s football season. The Buckeyes on Saturday and the Browns on Sunday, ya know? This whole Saturday and Sunday mass schedule doesn’t line up with the season at all. I can’t believe you don’t get that! Why can’t we just move mass to Monday until after the Bowl Games and the Super Bowl. Tell you what…just forget about it. I’ll be here on Sunday and I’m going right to God on this one. You just make sure he’s in Church this weekend so I can tell him directly.” Well, we know that God is always in Church, and that He does, indeed, hear every petition a member of His flock makes. Like Danny Meyer, the great restauranteur in NYC who holds that the customer is NOT always right, but does have a right to be heard. Actually, this example gives me some comfort, some direction in how we might deal with patients who talk to our staff in such a brassy, entitled manner. We are definitely not God, or even the least bit God-like, but like Danny Meyer and God, we can always listen, as we know they do, and we will always politely offer them an answer.

Sometimes, the answer is “no”.

The Bellevue Death Ray, Revisited

Man, what a place Bellevue Hospital must’ve been back in the day. It was crazy enough in MY day in the mid-1980′s. Bellevue is arguably the most famous hospital in the world, famous mostly for the treatment of psychiatric patients, and made all the more famous by the Christmas movie “The Miracle on 49th St.” in which Santa Claus was institutionalized in one of Bellevue’s top floors. For those of you who don’t know Bellevue Hospital, the top six floors of a 30 floor tower were (are?) reserved for psychiatric patients, at least one of them for psychiatric patients who hail from Rikers Island.

I’m not really sure why, but I’ve been thinking a lot about Bellevue recently. My experiences as an ophthalmologist in private practice in the suburbs of Cleveland, Ohio really have exactly nothing in common with my experiences as an ophthalmology resident on the lower East Side of New York City. Nonetheless Bellevue has been on my mind. Since I’ve been thinking about it I thought I’d share some stories about Bellevue and about my time as a resident at all of the NYU hospitals. This will also give me an opportunity to introduce you to some very special, very interesting characters whose lives crossed paths with mine.

Irwin Siegel was an optometrist with multiple roles at Bellevue Hospital. His most important role for me and my fellow residents was to teach us about optics and refraction, the science and technique of prescribing glasses and contact lenses. Dr. Siegel was also a noted researcher in the diagnosis and treatment of retinal diseases, specifically diseases of the macula or center of the retina; there is actually a syndrome named after Dr. Siegel and two of his partners.

Dr. Siegel was a fascinating man, especially fascinating to a child of suburbia like me. The prototypical New Yorker, Dr. Siegel lived his entire life in Brooklyn and Manhattan. He did not own a car, and used some form of public transportation for more than 95% of his travels. You got the sense that any forays outside the island of Manhattan were viewed as akin to a ride on the “Heart of Darkness” express. The guy simply reeked of New York, and he spent his entire professional career at Bellevue Hospital.

Recall that my life’s memories are wrapped up in eyecare, optics, and the optical industry. My father’s first job was at American Optical in Southbridge Massachusetts, at the time the largest ophthalmic manufacturing company on the planet. The very first lasers were actually developed in the laboratories of AO. In the early 1960s Dr. Siegel and his partners were doing research on lasers at Bellevue. Now, as you can imagine, something as powerful as the energy of the laser light had also come to the attention of the U.S. Military. So comes the story of the Bellevue Death Ray!

Dr. Siegel and Dr. Ron Carr were doing laser work somewhere in the bowels of Bellevue. This would have been in the early 1960s, and the laser they were working on was an enormous mechanical monstrosity, a piece of equipment that took up more space than most upper East Side kitchens. Not only was it physically enormous, but the generation of a single pulse of laser took well over a minute, a minute filled with a crescendo of sound not unlike what one would experience when a jet engine is engaged . Imagine a room, half filled with this exotic piece of near–science fiction equipment, surrounded by white–coated scientists all wearing goggles that look as if they had been spirited away from a Mount Everest expedition. Add in a few very senior military officers in full dress regalia and the scene is set.

The officers visiting from the Pentagon really had no idea what to expect. They were intrigued by this new technology, interested to see if there might be some military application. Dr. Siegel noted that he and Dr. Carr were mostly bemused by the presence of the officers, although he did admit being a little bit impressed by the two-star general in their midst. The  experiment/demonstration was set up, on one end of the room the monstrous laser, on the other end of the room a rabbit in a box, his head poking through a hole, the laser aimed at his left eye. Goggles were donned and the switch was flipped.

The laser came to life, slowly building energy in the rudimentary laser tube, the whine and the clang and the clatter growing in intensity with each passing second. Dr. Siegel and Dr. Carr stood calmly to the side, ignoring the laser and concentrating on the rabbit. The officers, on the other hand, slowly crept back away from the laser, trying to melt through the wall, and failing that trying to become as small as possible. Two-dimensional, if possible. The wail of the laser grew… the sound filled the room… the wail, the clatter, a crescendo… BAM!

And then, silence. The doctors and the officers took off their goggles. They walked over to the  box and discovered that the rabbit was dead. Immediately one of the colonels started doing a jig. “We have a death ray! We have a death ray!” He began to run for the door, headed for the telephone (no cell phones or sat phones in those days). “Well, hold on a minute,” said Dr. Siegel. “Let’s just take a closer look.” It turns out that rabbits are not terribly bright creatures, and that when they are frightened they tend to forget how to move backwards. This poor bunny, the only creature in the room without Ed Hillary’s goggles, had been so frightened by the noise of the laser that he literally suffocated himself, pushing against the rim of the hole in the rabbit box in an effort to escape.

When Dr. Siegel looked inside the rabbit’s eye there was a single perfectly round burn, approximately 2 mm in size in the middle of the rabbits retina. There,  in the space of approximately 5 minutes, was born and died the Bellevue Death Ray.

The epilogue of this story is rather interesting, though. About 10 years later, after numerous refinements of both the production of laser energy and the focusing of that energy, one of the most important trials in the history of medicine took place using focused laser light to prevent vision loss from diabetic retinopathy. The Diabetic Retinopathy Study was the very first prospective, double–blind, randomized clinical study done on a cooperative basis across the entire country, the type of study that is now considered the ‘gold standard’ for medical research. The results of that study have saved countless individuals from a life of blindness due to diabetes.

This is where I trained, and men like Dr. Siegel who told us this tale from Bellevue Hospital as part of our optics classes, is one of the men who trained me.

Agreeable?

When did a difference of opinion become a de facto conflict? When did the evaluation of another come down to whether or not they hue to a fine line of agreement on a single, or a few, or G0d forbid, every issue? When did this phenomenon morph into one in which a difference of opinion then becomes the basis for labeling another as ‘good’ or bad’?

Am I the only one who’s noticed this?

I’m not talking about a difference of opinion which is then followed by a concerted attack, one that forces you to identify the holder of the other opinion as ‘bad’ and enemy. There’s nothing new to see there. One only has so many cheeks to turn. Eventually you need to fight or flee an attack, but that’s not what I’m talking about.

On a personal, local, and national level we could once identify broad stroke issues on which we could generally base a level of agreement or disagreement, very few of which would be a ‘deal-breaker’ when it came to civil discourse. The first part of this, the existence of broad stroke issues, remains true. What is fundamentally different in my mind is how un-moveable many of us have become on ever more minute details as we drill down from the 30,000 foot view. All well and good, I suppose, to seek fidelity to an ever more granular level of agreement on whatever issue is at hand, especially in this age when we have ever greater ways in which to find and connect with people of a like mind.

What I don’t get is the subsequent labeling of any and all others as “bad”. Unworthy. Lesser in some way because they do not agree at every level with a particular–very particular–point of view. As I remember it the “80-20″ Rule pretty much applied to belief systems as well as business: if you shared 80% of your beliefs with another that was plenty good enough to allow a friendship, and certainly enough to inoculate against a conflict. Now? Seems like something more like the “980-20″ rule: only the smallest amount of the most trivial difference of opinion is permissible. Anything more than nuance between people and they’re going to the mattresses. Anything more than nuance and we’ve identified something other, something lesser, something to destroy.

What’s up with that?

You could say that anything other than full devotion to a cause , concept or worldview is not pragmatism but something more akin to weakness. An inferiority of spirit, perhaps. You could say that nothing other than total fidelity to some grand theme or concept is acceptable and brook no deviation from a one, true path. I would say that the world is infinitely too complex to approach life in this manner. I would further say that to do so needlessly isolates you from people who might very well bring infinite joy to your life despite differential nuance or even a fundamental disagreement on any one issue. Living and letting live rather than seeing a difference of opinion as identifying the other as an enemy might just mean a more pleasant life filled with more people who might be better described as friends, or at least friendly.

At the very least perhaps we could just agree to disagree and be on our way.