Random Thoughts from a Restless Mind

Fly an airplane. Take Dad’s car on a date. Finish your residency and perform your core surgery without a professor over your shoulder. The first solo is a milestone event, and many such events become life’s touchstones to which we return time and again. My first solo attempt to log on and clear out my “Basket” on EPIC, the EMR that I am mandated to use in order to continue to operate at a surgery center where I’ve been the primary ophthalmologist for >15 years? Meh, not so much.

At 0 Dark 30 I was doing glaucoma lasers, and I finished well before I was due in the office. Perfect time to log onto a dedicated terminal, take a look at the items demanding my attention, and get on with the real work of eyecare. Full disclosure: I called the IT guy with whom I’d bonded a  couple of weeks ago to see what I should do with the pharmacy boondoggle and received permission to blow off all of those entries. Whew! Home free. I sat down and went through the log-in process, just like my new best friend had shown me. No love. 0 for 15. Unable to log in.

BZZZZTTT. Sorry. Johnny, tell Dr. White about our lovely parting gifts for losing contestants.

Might turn out to be more like expected after all.

I am about to be forced to use the EMR abomination know as “Epic” in order to continue to perform surgery at a particular institution, one where I spend ~10% of my clinical time. My work there is very profitable for the institution; I am not paid by the institution. At present my administrative load is 2X what it was 5 years ago, but the majority is borne by my staff. Once I am required to use their EHR my administrative load will increase at least 20X and I will bear all of it.

Why? My forms are standardized and fulfilling my part of the administrative load presently requires approximately 8 signatures for each case. 8 swipes with a pen on 8 pages layed out before me and marked “sign here”. Time = 0:10/case. Soon I will have to sign into the system for each case and move through a series of ~5 steps to reach the point where I will perform the digital version of my sweeping pen. Time, I am told by colleagues using the system to achieve this, = ~4:00/case. Let’s be generous and assume that they can’t possibly be correct, that it can’t possibly take 4:00 to do digitally what I now do with a pen (Heaven help if I have to enter pre- and post-op orders w/out standard forms!), and that it’s only 2:00. A typical OR day includes 20+ patients. 40 minutes added minimum. Did I mention that I have to do it TWICE because you can’t sign an op note right after surgery?

Lest you think this 52 yo doc is a Luddite and has avoided any and all such technology let me assure you that quite the opposite is the case. We have had an extremely efficient EMR in our office for 7 years; our management and scheduling has been done by computer for 16. My home is littered with Apple products. I’m a buyer of tech WHEN IT MAKES SENSE.

Unfortunately, it appears that I’m about to be forced to be a buyer of this “meaningless use” very soon. I thought I’d share the experience with you here. I’ll keep a log under “The Epic Adventure” and I’ll record not only my experiences but also the time I will be forced to “invest” in learning how to use the system and the time it takes me to comply with its requirements.

It promises to be quite a ride, albeit a rather slow one

8:00 p.m. on a Friday night. An urgent page from Express Scripts. “Approval needed for sleeping medicine, Agnes Jones*. 800–333–4444.” Agnes Jones is a nursing home patient with a brain tumor.

4:59 PM, Friday afternoon. Telephone call from CVS pharmacy. “The nonsteroidal anti-inflammatory eyedrop that you prescribed is not covered by Mrs. Jones’ insurance company. We need your authorization to change to the generic version.” We told Mrs. Jones in writing that the generic version was inferior, caused pain, and had 10 times the complication rate. On Monday.

7:30 AM, Sunday morning. Telephone call from answering service. “Doctor, the prescription that you sent electronically on Tuesday for Mrs. Jones was written incorrectly. Please correct this and refile it immediately. Please remember that your status as a provider is contingent upon meeting our customer service standards.” Confirmation of receipt/prescription filled was received on Wednesday.

And, my very favorite, most recent telephone call, this one from the daughter of one of my patients. “Dr. White, NALC needs you to send them a letter proving that my father’s eye drops are not prescribed for cosmetic purposes.”

Welcome to the world of the American physician in the modern era. There are, of course, a host of entirely appropriate responses to all of these pages, beeps, and phone calls. However, this last one put me over the edge. I sat at my desk with the message in front of me, closed my eyes, and thought about how I’d REALLY like to respond. The totally, truly amazing part about this request to justify the eyedrop prescription was that, not only was all the information necessary to cover this already on file at NALC, and not only did a real, live human being actually look at this file, but she admitted that and gave me her name! Ya can’t make this stuff up.

“Dear Alex:

Thank you for this opportunity to express my thoughts about some of the pitfalls associated with the pending ‘meaningful use’ regulations for computerized health records. After you personally reviewing the record you requested information about eyedrops that I prescribed for one of my patients. There is apparently a concern about whether or not this patient is using said medication for cosmetic rather than medicinal purposes. As you know, among the more significant ‘meaningful uses’ of electronic medical records are to make sure that everyone has the same exact information about a particular patient, to utilize this information in such a way that proper care is ensured, and to be more time-efficient for the patient, doctor, and everyone else involved in the care process.

If you will open up your file again regarding the patient in question, JOSEPH Smith, you’ll see that, had meaningful use activity actually been applied, this entire communication could have been avoided. Had you actually read the file you would have seen that MISTER  Smith is an 87 YEAR OLD MALE with a long-standing diagnosis of GLAUCOMA. As your software no doubt shows, the eyedrop Lumigan  is a first line medical treatment for glaucoma. All of this information is contained in your database since Mr. Smith has been taking this medication for no fewer than five years, and the bill for his office visit was paid in full by NALC, diagnosis: glaucoma.

A copy of this letter will be forwarded to my US Rep. and two senators, the FDA, and CMS along with a note asking how they propose that all of their fancy new laws about EMR and ‘meaningful use’ will prevent lazy and incompetent file clerks from blinding my patients.

I trust that the information in this ‘old–school’ letter is meaningful enough to prove that Mr. Smith’s use of Lumigan is not for cosmetic purposes.

Sincerely,”

——————————————————–

“Dear Alex,

Attachment: Pic.JSmith.jpg

Seriously? Really? You would like me to prove that my toothless, 87-year-old patient named JOSEPH is not using his glaucoma drops for cosmetic purposes?! The guy with the electronic bill in your system with a diagnosis for glaucoma, taking three other glaucoma medicines, all for 20 years? The Joseph Smith who can’t be bothered to remove the 11 skin cancers growing out of his face like barnacles on a sun-scorched barge? COSMETIC?

This is a joke, right?

Sincerely,”

——————————————————————-

” Dear Alex,

You caught me! But please, don’t tell anyone else. We have the largest population of semi retired 87-year-old drag queens in America in our practice. They just can’t let it go! We have been prescribing medicines so that they could maintain their long, luxurious eyelashes forEVER. I mean, who WOULDN’T rather have long, thick, natural lashes, especially after a lifetime fussing with those falsies and all that icky, sticky glue. Joe has been SO happy!

It’s amazing how important it is for him and all the ‘girls’ to be able to bat their eyelashes at those cute boy orderlies in the nursing home.

Not that there’s anything wrong with that…

Sincerely,”

Sigh…

*All names are fictitious, of course. The examples are not.