Random Thoughts from a Restless Mind

Apple just released a smaller Tablet, the iPad Mini, and was razzed by the cognoscenti because it broke no new ground. “Reactive.” “The first  time Apple plays defense.” “Nothing to see here, people. We’re walking…we’re walking.” While the Apple Fan Boys (and Girls) were lining up to add to their Apple quivers, the rest of the consumer world reacted with a communal shrug. Why? No real innovation, and that was a surprise in the world of consumer electronics recently dominated by Apple’s serial innovation.

It makes you wonder a bit, doesn’t it, why there’s so little innovation in the world of medicine when it comes to the storage and transfer of information. With all of the cool stuff already available (voice recognition, “pens” that convert script to text, intuitive “next step” software), why do we have such stodgy, clunky software attached to yesterday’s hardware in all of our EMR choices? For heaven’s sake, we don’t even have a universal platform upon which the various and sundry products are built, and so we continue to have interoperability issues more than 10 years after folks started putting this stuff into play. Why is that?

Every computer product I’ve bought and used over the last 10 years has been easier to use than the one it replaced. Each one has allowed me to do more, and usually with a smaller and less expensive gadget. I know it’s a cliche by now, but my phone has more computing power than the first SERVER I bought to run an entire medical business. For $400. I can talk to it, order it to do stuff, and get all kinds of help I never needed faster than I could realize I needed it, and it fits in my pocket. Yet in a medical office state of the art consists of serial drop-downs and mandatory field entries that may or may not include anything germane to my patient. Able to chat with my cell phone through a bluetooth headset, my EMR demands my full, undivided attention, with gaze fixated on screen.

How come?

In the world of consumer electronics the game is all about predicting what the next, big “gotta have it” gadget or service will be. The most exciting and successful products almost invariably carve out new territory and then go on to viral-like growth because they fulfill a need. This kind of technological progress is so powerful that the people who buy this stuff abandon perfectly functional gadgets that do everything one needs or wants in favor of that next, new-better gadget. This phenomenon in turn drives the makers of consumer electronics to create, to innovate. But not in medicine.

Why is this so?

The so-called “market” for EMR is simply non-existent. The power of innovation, either in response to consumers established, stated needs and desires or in anticipation that something new and better will simply take off in the marketplace is non-existent. The kinds of companies that seemingly come out of nowhere were bludgeoned by government mandated requirements that tiny, bootstrap companies just couldn’t fund the effort. Big companies that innovate like a tiny start-up and create whole, new categories, like Apple, simply didn’t. They all just doubled down on old tech and old ideas, an entire industry making iPad mini’s and calling it progress. The perceived danger of innovating and then having a revolutionary product found to lack “meaningful use” stifled the entire industry. Innovation in EMR was DOA.

And now? Now we have the largest medical institutions in the country abandoning their own efforts at software development and marching like lemmings to the Epic sea. The real-world analogy would be the government saying that you could create any type of gadget you could think of to listen to music, but you can only sell record players and vinyl albums on which you must listen to the songs in the exact order in which they appear on the disc to be assured that the check would clear. Oh, and the doc or nurse could only listen through noise-cancelling headphones that would need to be removed in order to talk to a patient.

It doesn’t have to be like this, of course. All it takes is one company with a little vision and some gumption to find a single big-name player with the courage to see that the status quo is sick. Sure, the vast governmental bureaucracy needs to fix a target and then get out of the way so that something that looks like a real consumer electronic product can emerge. That’s all, really. One product that feels like as “0f course” as the iPod, discovered and purchased by one person who folks watch like TechCrunch, a dispassionate and largely uninterested government standing to the side, idle.

A 7″ computer that could power my company 7 years ago hits the market to a collective yawn? Is it really so much to ask for this type of innovation in EMR?

OK, so maybe this part was my fault. I probably would be a bit better at this Epic thing if I did it more frequently than once every two months. Guilty. The thing is, though, that every little thing Epic asks me to do has either already been done on paper, would go faster if it was done on paper, or both.

It takes two discreet steps to enter the software program, even if you are in a CCF institution and working on a CCF computer; it’s even more complex and takes three steps from the comfort of your own computer. I get the security thing; really, I do. I tried it both ways and failed. Epic failure. Again. So once again I had to call in the cavalry in the guise of the physician support team just to get into the system, finally achieving this milestone event after 3 attempts and a total of 100 minutes of work.

Success, right? I’m in. Nothing to do now but clean up my charts, sign this, attest to that, and away I go. Sure…about that. In the interim between my visits there’d been an upgrade, ostensibly to make using Epic easier. Another 45 minutes of frustration ended up in another phone call and a personal visit by one of the support staff to guide me on my adventure. Kinda like being roped to a mountain guide when you really have no business climbing that particular mountain, except on the mountain you chose to be there.

You’re probably wondering why there was such a big interval between my visits to the “mountain”, and why I chose to continue my Epic adventure now. Both have rather simple answers. I hate everything about this process and this program; I feel oppressed, literally, forced to use a bloated,  inefficient bureaucratic load of “make-work” that adds nothing but time and effort to my day, and so I naturally avoid it for as long as possible. How long? Well, long enough this time that the reason I found myself roped to my guide was the Registered Letter informing me that I’d ignored all of the notifications that I was delinquent in my charting and had therefor “voluntarily resigned” my staff position. Another 30 minutes with my guide and my slate was clean.

How, you might ask, had I possibly allowed myself to “voluntarily resign”? I’ve been a doc for some 25 years; I know the medical staff rules. I’ve been signing charts forever. My address, fax number, and email are all unchanged, and I’ve never missed a notification from the hospital before. Despite my obvious, transparent disgust with Epic and everything it imposes on me, it doesn’t make any sense to let that jeopardize my ability to do surgery at this institution by petulantly ignoring my medical staff requirements. How did this happen?

Easy. All of the notifications were messages only available when you log into Epic.

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.

As I posted a few weeks ago, in order to continue to use an outpatient surgery center where I have performed surgeries for 15 years or so, I am now required to use the electronic medical record EPIC. My hope had been that I would be able to continue to run “under the radar” by utilizing my pre-–dictated notes and standard orders, signing the papers as I have done lo these many years. Tragically, this was not to be. Having come to this realization about a month ago I reached out to the IT department and asked for training on the system. Being the somewhat self–involved surgeon that I am, I naturally assumed that a single phone call or e-mail would see multiple individuals leaping into action in order to help me so that I might continue to use that surgery center and generate revenue for the hospital. Silly me.

Four weeks, a dozen conversations, several e-mails, and I am assured more than several telephone calls later, I finally received a call from IT and one of the physician–advocates/trainers. I explained that I had a back log of signatures (little did I know!), and that I would be taking ER call soon, and did he perhaps have some time available to show me how to use the EMR? In the first of several remarkably positive little things in this process, Andrew did, indeed, have some time available the very next morning when I, too, could sit with him for a little bit.

Andrew himself was one of those little surprises. And ex–cop who had put himself through nursing school with the intention of using his nursing degree as a springboard to management, he informed me that he was one semester away from an MBA. It was clear he was anticipating a hostile interaction; this had been his typical experience when teaching physicians the system, especially private practice physicians. I liked him instantly, we connected, which probably contributed to the speed with which we flew through phase 1 of my indoctrination.

This can’t be all good, of course, otherwise there would be no reason to do this series! After learning how to get into the system (no, you cannot change your username), we looked at my chart deficiencies, specifically op notes that needed to be signed tracing back to November. I cleaned up all the old stuff, and then we got stuck with all of the charts that were sitting there from last week. Apparently part of the efficiency of the system allows the medical records department to put you on the “bad boy” list as soon as the case is done! We agreed to ignore these deficiencies since these would still be paper charts needing to be signed and moved on to pharmacy orders.

This was rich. I looked at about 200 orders with a “signature required” tag. Things like IV orders, and medicine injected to into the IV. Some were anesthesia orders which have no business on my list, and essentially all of the rest had already been signed. Andrew told me he’d taken a look at my in basket before we met and deleted three or four months of the pharmacy orders. I think the number he used was 800,000 orders! Whoa, maybe this isn’t going to go as well as it looks like it might. There is no connection between the electronically entered pharmacy orders and the signatures on the order sheets! 30 some odd orders per patient, each one individually entered and requiring a signature. I did 22 cases yesterday! Are you kidding me? This is what my colleagues were talking about when they mentioned the four minute per chart rule.

Like I said, though, this was a surprisingly positive interaction. Andrew took a couple of screenshots and said that he was going to sit with the IT magicians and see if we might be able to figure this particular one out. Man, that’s gotta work. I mean, the whole exercise took me about 45 minutes, and I didn’t even learn how to ENTER an order.

I can sign one, though. I’ve got some ER call coming up, and I’ll have to do some–patient consultations as part of my responsibilities. I’d better polish up my “helpless look” and rehearse my supplications. Getting someone to take verbal orders is gonna be the key to salvation.

More to come…

Skyvision Centers has a subsidiary company called the Skyvision Business Lab. We do business process research for pharmaceutical companies, medical device companies, and other medical businesses in the eye care arena. One of the companies we have worked for is a very cool company that produces animated educational videos for ophthalmologists and optometrists. I had an interesting experience while talking to their chief technology officer. It was interesting because the conversation proved our basic reason for existence at the Business Lab, that it is impossible for any company to develop, sell, and install any kind of product in our world without understanding the ins and outs of every day activities in an eye care practice.

Of course, I always find it extremely interesting when I’m right!

It was a tiny little point, really, but how could you know something this small and seemingly insignificant unless you had spent time on the “frontline” of medical practice? The chief technology officer for the video company was frustrated because doctors and their staff were not using this really cool product that they had purchased. Furthermore, because they weren’t using it, they were failing to buy downstream products from the video company. As it turns out the salespeople for this company were telling the doctors that this particular product should be “turned on” by the staff at the front desk of the office. This is exactly the wrong place because the front staff personnel simply have neither the time, nor the understanding, nor any incentive whatsoever to do this! The product actually works beautifully if it is “turned on” by the back-office staff. Bingo! Problem solved.

So what does this have to do with Electronic Medical Records (EMR), and for heaven’s sake what does this have to do with underpants? It’s simple, really. When was the last time you bought a totally new type of underpants, underpants that you had never seen before, and underpants that you had certainly never worn before, without trying them on? Furthermore, what’s the likelihood that you would allow someone else to design, fit, and choose a style  of underpants for you if that someone has not only never met you but has never even seen a picture of you?!  That’s the image I get every time I read an article about EMR.

In theory the concept of an electronic medical record that would allow permanent storage of every bit of medical information, with the ability to share that information between and among doctors and hospitals involved in the patient’s care is so logical and obvious that debating the point seems silly. If you have ever seen my handwriting, for example, you’d realize that the entire field of EMR was worth developing just to make doctors stop using pens and pencils! Trust me on this… the doctor hasn’t yet been trained who is also a specialist in penmanship.

I actually trained at  two of the pioneering hospitals in the use of electronic medical records, and indeed in the use of computers in medicine in general. Dr. Larry Weed and Dr. Dennis Plante at the University of Vermont were pioneers in the concept of using computing power to make more accurate medical diagnoses. Both the University of Vermont Medical Center and the Maine Medical Center were among the very first institutions to develop and implement digital medical records for the storage and use of clinical data like lab reports and radiology reports. In theory both of these areas make sense, but in practice the storage and display of clinical data is all that’s actually helpful in day-to-day practice.

If this is the case, if the acquisition, storage, and retrieval of critical data is helpful, the next logical step must be to do the same thing with the information obtained in doctor’s offices, right? Well, in theory this makes a ton of sense. The problem is that nearly none of the EMR systems now in place have been designed from the doctor — patient experience outward; they’ve all been designed from the outside in, kind of like someone imagining what kind of underpants you might need or might like to wear, and making a guess about what size would fit you. With a few exceptions, tiny companies that are likely to be steamrolled in the process, every single EMR on the market is the wrong fit for a doctor and a patient.

Why is this? How could this possibly be with all the lip service that is being paid to the doctor — patient relationship and the importance of getting better care to patients? It goes back to that same tiny little problem that the medical video company tripped over: it’s really hard to know how something should work unless you spend some time where the work is going to be done. Electronic medical records in today’s market are responsive to INSTITUTIONS, insurance companies and governments and large hospital systems. System before doctor, doctor before staff, staff before patient. Today’s EMR’s have been designed with two goals in mind: saving money and reducing medical errors. Should be a slamdunk at that, right? But even here the systems bat only .500, producing reams of data that will eventually allow distant institutions to pare medical spending, but neither capturing nor analyzing the correct data to improve both medical outcomes and medical safety. Fail here, too, but that’s another story entirely.

So what’s the solution? Well for me the answer is really pretty easy and pretty obvious. Send the underwear designer into the dressing room! Program design, programs of any type, are one part “knowledge of need” and one part plumbing. How can you know what type of plumbing is necessary unless you go and look at the exact place where the plumbing is needed? How can you know what size and what shape and what style of underwear will fit unless you actually go and look at the person who will be wearing the underwear? It’s so simple and so obvious that it sometimes makes me want to scream. Put the program designers in the offices of doctors who are actually seeing patients. Set them side-by-each. Make them sit next to the patients and experience what it’s like to receive care.

THEN design the program.

I’m available.The  Skyvision Business Lab is available. I have a hunch that the solution will hinge on something as simple and fundamental as my example above — front desk versus back office.  It doesn’t necessarily have to be me, and doesn’t necessarily have to be us, but it absolutely is necessary for it to be doctors and practices like Skyvision Centers, places where doctors and nurses and staff members actually take care of patients. Places where patients go to stay healthy or return to health. Places where it’s patient before staff, staff before doctor, doctor before system, and all before the 3rd party payer.

For whatever it’s worth I’m 5’8″ tall, I weigh 150 pounds, and I’m relatively lean for an old guy. I guess it’s a little embarrassing to admit this… I still wear “TightyWhiteys”, but I’m open-minded. I’m willing to change.

Just take a look at me first before you choose my underpants for me.

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.