Doctor Rob

There was a hole in the wall of our bathroom that was a painful reminder of a bad encounter with a plumber.  Yes, that hole has been there about a year, and it has been on my to-d0 list for the duration, daring me to show if I inherited any of the fix-it genes I got from my father.  Why not hire someone to come fix it?  I also got (as I mentioned in my last post) dutch genes, which scream at me whenever I reach for my wallet.  So this hole was giving me shame in surround-sound.

I attempted to fix it the hole last year, even going to the degree of asking for  a router table for my birthday.  Since there was previously no way to get to this all-important access to the shower fixture without cutting through the sheetrock, I decided I would take a board, cut it larger than the hole, then use the router to make a rabbet cut so the panel would fit snuggly.  Up until then, I thought a rabbet cut was a surgery to keep the family pet population under control, but my vocabulary was suddenly expanded to include words like rabbet, roundover, chamfer, dado and round nose.  Unfortunately, my success only came in the realm of vocabulary, as I was not able to successfully master the rabbet cut without making the wood become a classic example of the early american gouge woodworking style.

I am not sure why, but something inside me told me today was the day to give this another shot, and to my shock (and that of my family), I was successful!

Yes, there still is a minor wallpaper issue, but note the total absence of gouges!

Also note this fine example of the roundover cut.

This home project is actually a late comer to the DIY party I’ve been holding for the past few months.

• Don’t like your practice?  Build your own from scratch!
• Don’t like the health care system, build a new one!

My latest DIY venture is in an area I swore I’d not go: I’m building my own record system.

There are several reasons I’ve avoided doing this DIY project:

1. If I fail, I’ve wasted a bunch of time I should have been building my practice.
2. If I succeed, I don’t just have a practice to manage, but a piece of software.
3. I tend to get obsessed with details, losing hours coming up with elegant solutions to problems for which simple solutions are available.
4. It requires that I spend far too much time thinking about HIPAA and security issues.  I hate that kind of thing.  It bores the socks off of me.  I fell asleep three times while writing this bullet point (and I have no socks).

Business is good; we are up to 250 patients and are managing the volume pretty well.  But I’ve had to keep a cap on growth while I figured out what system I would use to run the practice. Obviously, EMR systems designed to produce enough E/M vomit to scare away Medicare auditors don’t fit with my business plan. Other systems seem to have become so obsessed with “meaningful use” that they don’t do basic business functions.  Expecting a system designed to work with the Economics Through the Looking Glass of American healthcare to function in the real world is folly, and so I had to choose: do I stay with my current non-system and let the quality of my care suffer, do I keep growth of the practice to a minimum, ignoring the reality of 3 kids in college next fall, or do I give in to the belief that I know what I need and can build a computer system that will work with my type of practice?

I decided on what’s behind curtain number 3.  Unfortunately, this all happened just as I agreed to an interview with a local TV station – an interview that went viral and now has people as far away as Idaho and San Francisco wondering if they can be my patients.  Now the pressure is really on to make this thing work.  I can no longer be indecisive; I will either live by the database or die by it.

So far, it’s been going well.  Despite a few “unfortunate” moments where I deleted all records of everything (thank goodness for paranoia about backups), I have broken the code of working with a relational database, and my nature as an internal medicine problem-solving nerd has served me well.  In truth, this is not much different from what I did with the EMR system at the old practice.

• I think about where the greatest pain is for me and my nurse, and fix those problems.  Where can time be saved, and jobs be made simpler?
• I think about where the greatest risks for patients are, and fix those problems.  What things are easily forgotten or missed?  How can I set the system up so it assures the safety of my patients?
• I think about where I want to go with the practice in the long run, and set up a system that will set us up to go in those directions when we are ready.
• I think about the questions I ask myself when dealing with a patient, the information I want to know the most, and put that information in a place where it’s easily accessed.

In reality, the software borrows heavily from software real businesses use:

• Contact Relations Management to keep track of interactions with customers (patients)
• Business financial management to keep track of costs and of who has paid (and who hasn’t)
• Document management to handle the reams of information flung at me on a daily basis.
• Task management to keep important tasks in front of me and my nurse (and eventually patients)
• Spreadsheets to organize numbers
• Reminders to tell when important things are due
• Communications systems both between office staff and with patients

It’s really a hybrid of all of these, with the additional plan to securely share much of the data with my patients online.  My hope is to build something good enough to get the interest of someone who actually knows what they are doing in writing software.  I know what problems need to be solved, and am learning much about how a good database program can do that (I am using Filemaker Pro because it’s cheap, it’s easy, and it works on both Macs and Windows), but I know my limitations.

I still have no desire to become a software tycoon.  I am doing this only because it’s the only way I could see to make this practice work.  The practice is still at the center of my motivation.  If it doesn’t help me serve my patients better, I won’t do it.  The amazing thing is that we used it all of last week and my nurse didn’t quit.  That’s a good start, but the real test comes this week, as we take on the barrage of new patients brought on by our recent publicity.

I’ll keep you posted.

I remember going to see the movie “Oliver” in the theater when I was a kid.  Since this was my first movie in a theater, my mom made me a treat: a bag full of raisins and chocolate chips (Raisinets for Dutch people) and sent me there with my sister.  It was a fine film, with Oliver getting kicked out of the orphanage when he wanted more gruel, the dastardly Bill Sykes threatening Oliver and sweet Nancy, the funny and clever artful dodger and Fagan teaching Oliver about life on the street, and with (spoiler alert!) good overcoming evil in the end Oliver getting adopted by a rich dude so he can get all the gruel (or real Raisinets) that he wanted.  And though my memories of the movie are still vivid, my strongest memory was the look on my sister’s face when I walked out of the theater covered with melted chocolate chip goo.  It went into family lore (and wouldn’t have happened if they had sprung for Rasinets, I might add).  I think they still don’t trust me with chocolate chips.

The key line in the film comes when Oliver loses a bet and goes up to the gruel-master and says: “Please Sir, I want some more.”  Which, as I am sure Oliver expected, causes the gruel-master to break into the song, “Oliver! Oliver! Never before has a boy wanted more!” and the whole dining hall to pull out musical instruments and singing harmony to the gruel-master’s admonition.

I can see why Oliver was scared.  A whipping is welcome compared to his whole world breaking into song and dance.

Asking for “more” has caused trouble over the ages.  Adam and Eve wanted more food choices, the people of Pompeii wanted more mountain-side housing, Napoleon and Adolph Hitler wanted to spend more time in Russia, and America wanted more of the Kardashians. We can all see what destruction those desires reaped.

Americans have been viewing health care the same way, always wanting more: more antibiotics, more technology, more robots doing more surgery, more expensive treatments for more diseases.  The result: health care costs more in America than anywhere else.  Some folks think that our “more” approach makes our health care “the best in the world,” after all, where else can you get so many tests just by asking.  MRI’s for back pain, x-rays for coughs, blood tests for anyone who dons the door of the ER.  ”Tests for everyone!” shouts the bartender. “Tests are on the house! ”

They aren’t, of course, and we are paying the price for “more.”  This hunger for “more” is fueled by the media’s fascination for the “latest thing,” the long disproved idea that technology will solve everything, and docs who aren’t willing to take time to explain why it’s actually better to do less.  It’s hard to do, when we are paid more to spend less time with patients, and when the system is willing to pay for more and more.

There is a voice against this: the “Choosing Wisely” campaign, which argues against unnecessary treatments and tests.  This is a welcome voice of reason in the cacophony of cries for “more.”  Yet the battle goes against the irresistible tide of our payment system.  The root problem is this: there are a whole lot of people whose jobs depend on America’s addiction to “more.”  The payment system has created an ecosystem that thrives off of waste (of which I once wrote an allegorical fantasy).  True health care reform will be catastrophic to many who work in health care, with many very nice and hard-working Americans losing their jobs at the ACO factory, at Meaningful Use Inc., and even at Stents-R-Us hospital here in my home town.

This is what you get when you make disease more profitable than health, when we treat problems instead of people.  The simple fact that our system would be destroyed if everyone got healthy should tell us something is terribly wrong.  Doctors want their offices full, not empty.  The goal of every patient – to be healthy and to stay away from the doctor – goes directly against the economics of “more.”

I have always tried to be a non-test orderer.  I was trained well by docs who believed it weak-minded and bad care to blithely order tests and prescribe medications without a well-defined reason.  This has always made it harder for me, as it’s far more time-consuming to explain why a drug or test is not needed than to simply order it.  But in my new world, one in which an empty office is a good thing, I’ve found my patients much more open to my aversion to “more.”  The main reason for this is that I am giving them more of me.  More of me means they can call if they don’t get better, or if their symptoms develop.  They know I won’t force them to take more of their time and spend more of their money to get my attention.

Ultimately, I want my patients to see as few doctors, be sick as infrequently, and be on as few drugs as possible.  I hope to wage an all-out assault on “more.”

Here are my rules to battle “more”

1. Never order a test that doesn’t help you decide something important.  Ordering tests “just to know” does much more harm than good.
2. Use consultants only to do things you can’t.  Orthopedists will aways give an NSAID and physical therapy for problems, so I don’t send patients to them unless they’ve failed those treatments (where appropriate).  I am just as good at ordering PT, and am more careful with NSAID prescriptions than they are.
3. Don’t give a patient a drug without explaining to them why they need it.  If I can’t make a good case for a drug, I shouldn’t be giving it.  This is not simply “to lower your cholesterol,” or “to treat your blood pressure,” but because doing so will raise your life-expectency.
4. Remember the number that really matters: how many birthdays a person gets to celebrate in health. I don’t care about blood pressure, LDL, or even A1c if treating it doesn’t raise the birthday total.
5. Don’t forget about another number: how much money patients have in their wallets.  There’s no point in ordering a drug they can’t afford, or making them pay for a test they don’t need (even when they ask for either).

I hope my new world of less overhead, less regulation, and less antacids for me continues on this trend toward less sick patients, less drugs, and less tests.  Perhaps I need to break into a song and dance number whenever my patients ask for “more.”

That would teach them.

It’s been a long time since I wrote a post.  My life, you see, is incredibly dull and boring.  There has been so little to write about that I’ve been at a loss.

No, actually that’s a load of crap.  It’s become a fantasy of mine to have such boredom.  In reality, my life is as un-boring as it could be.  It’s like the part of a story where everything is in flux, where little decisions have huge consequences, and where the inflection point between a comedy and tragedy is located.

So how’s my new practice going?  In some ways things are going about as well as they could.  My patients are amazed when I answer their emails or (even more surprisingly) answer the phone.  ”Hello, this is Dr. Lamberts,” I say.  This usually results in a long pause, followed by a confused and timid voice saying something like, “well…uh…I was expecting to get Jamie.”  Yet I am often able to deal with their problems quickly and efficiently, forgoing the usual message from Jamie to get to the root of their problem.  It’s amazingly efficient to answer the phone.

Financially, the practice has been in the black since the first month, and continues to grow, albeit slowly.  The reason for the slow growth is not, as many would predict, the lack of a market for a practice like mine.  It’s also not that I am so busy at 250 patients that growth is difficult.  In truth, when we aren’t rapidly adding new patients, the work load is nowhere near overwhelming for just me and my nurse.  In that sense I’ve proved concept: that it’s not unreasonable to think I can handle 500, and even 1000 patients with the proper support staff and system in place.

Which brings us to the area of conflict, the crisis point of this story: the system I have in place.  The hard part for me has been that I have not been able to find tools to help me organize my business so it can run efficiently.  I have well documented my realization that the EMR systems I’ve tried have not met my approval…To those who are students of writing, I just used a literary device called irony, specifically the irony of a ridiculous understatement.  I was able to use the term EMR without descriptions like “sucks at high decibel levels” or “crappier than a Carnival Cruise ship.”  Other example of this type of understatement include calling the Korean war a “Police Action,” and referring to congress as “a bunch of mindless fools.”…I’ve tried multiple solutions to this problem, only to have found little to improve my efficiency.  Sure, I can handle the current load of patients with the (non) system I have, but what happens when I grow?  I’m trying to build something that can grow, and something that others can emulate.  It’s obvious that I need a better system than I’ve found up to now.

So what do I need?  Surely the freedom from both E/M coding and the utterly ironic “meaningful use” criteria have made documentation of care much simpler, which they actually have.  The thing that most EMR systems devote 90% of their energy, documentation of office visits, is one of the smaller problems I face.  This has caused some readers (not on my blog, thank goodness) to conclude that I don’t need computers at all!  I can go real “old school” and return to the days of paper and illegible handwriting.  These folks are morons (and they get me very irritated) because they aren’t willing to think about what health care could look like if it weren’t corrupted by our pitiful system.  But, I ask, would they ask their bank to stop using computers and keep their financial records on paper?  Would they go to a travel agent instead of booking their flight online?  My suggestion that they write their comments to my posts on paper and mail them to me has not been met with any understanding or aplomb.  Sad.

Perhaps the problem is that I still use the term “medical record,” or (worse) “EMR” to describe what I am looking for.  While computers have been an important part in the corruption of the system, they have not been the cause of the screwing up, they have simply made the screwing happen at a much faster rate.

So what am I looking for?  The same thing I look for in a good story.  The best stories excel in three areas:

• Back Story – what happens before the crisis?  How did the person get to the crisis?  What are the motivations?  What are the inner conflicts?  What is at stake?
• Narrative – How well does the story-teller communicate what’s happening during the crisis?  How well do they describe the setting, the action, the dialog?  Do you feel what they feel?  Do you believe what they say?
• Resolution – How does the crisis get resolved?  Does it make sense?  Does it satisfy the listener?

These are also important parts of good medical care for any given patient at any given time:

• Back story – What has happened to the patient in the past?  Do they have diabetes?  Do they smoke?  Did their father have a heart attack at age 45?
• Narrative – What is going on now?  What are the symptoms?
• Resolution – What is the plan to get their problem resolved? Does it make sense?  Does it satisfy the patient?

So what system am I looking for to help this?

• Back story – Organization of data is key here.  The information needs to be complete, but it also needs to be well-organized.  It needs to prioritize important things (like the father with a heart attack at 45), and allow me to get a quick, accurate idea of who I am dealing with. Real world examples: Evernote, Wikipedia, Google.
• Narrative – Communication tools are key here.  While a typical EMR product stands in the way of communication, focusing instead on obfuscation by documentation, a good system would improve communication.  This has been the easiest to attain, using online communication tools and simply being free to answer the phone.  Real life examples: email, Twitter, Facebook, iPhones.
• Resolution – This is perhaps the hardest part (as it is in story-telling), and the worst done in our current system.  I am looking for a robust task-management system that can organize what needs to be done to get to where I need to go.  Examples: Wunderlist, online calendars.

This is a simplification of what really goes on, but it gives some idea of where I am heading.  My goal is not software, it is good medical care.  I am financially motivated to keep patients well, to efficiently answer their questions, and to handle their problems early, as it means I have more time and can handle more patients. Keeping patients well and at home was bad business for me in my former life (good riddance to that), but it is what patients want.  The more efficient I can be at meeting that desire of my patient, the better off both me and my patients will be.

They still will call, though.  I think they get a kick out of me answering the phone.

I’ve been going about this all wrong.

It’s not my dumping of the payment system so I can focus on care over codes, my use of technology to connect better with patients, or my vision of the “collaborative record” that is wrong.  It’s the fact that I am doing this without my most important resource: my patients.

I realized this while driving in to work this past week.  My first patient was a tech-savvy guy I’ve known for a long time.  Not only does he know me, and knows more than me about technology, he also is a regular reader of this blog (bless his heart)…and he still chose to switch to my practice!  So I was looking forward to running some of my ideas by him to see if my thoughts have strayed to the land of silliness (which they often do) or if I am actually onto something.  This line of thought led me to think about collaborating with him to work on my IT vision, since he does work for an IT company.  My line of thought then careened into the brick wall of the obvious: why just him?  I’ve been getting suggestions and offers for help from many of my patients, who are clearly intrigued by my direction and desirous to lend their expertise on the project.  So why not involve any of my patients who want to be part of this project?

So this morning I sent out an invitation to all of my current patients:

Many of you know that my biggest frustration at the moment (besides congress) is the total lack of software that supports a practice like mine.  I have a vision for what I need, but right now that is only possible using multiple tools in different places.  In other words, it’s confusing and chaotic — something the old way of doing health care was good at, but something I am trying to avoid.  As I’ve worked to figure out what to do with this project, I’ve been getting lots of offers for help and suggestions on what to do from some of my patients.  It occurred to me recently (not sure why it didn’t sooner) that I need to involve you, my patients, in the building of this system.  First off, you are real smart (as witnessed by your choice of doctors, of course), and could give me significant insight and help in this area.  Second, these are your records, and I believe this whole thing won’t work unless I build something that works for you.  Here’s what I need:

• A “brain trust” of patients who can help me get to the best solutions in this area.  I need a group of folks who know software/databases/IT (or who are good at faking it, like me) to discuss, brainstorm, and possibly build the tools that will work for both me and my patients.
• A group of folks willing to test various tools (Twistle is an example of one of those tools), and give me their opinions on what is good/bad/ugly about them.

We can meet in person, but since this is a geeky thing, I suspect most of our meetings will be held in the far reaches of cyberspace.  If in the end we come up with an ingenious piece of software, I have no hesitation but to share the piles of cash that fall out of the sky on us.  I don’t really care about that side of things, actually.  I really just want a system that will let me take care of all of you most effectively.

If you are interested, please let me know.

I am not sure why I hadn’t thought of this earlier (except that my mind is still affected by the “doctor is the center of the universe” reality-distortion-field that our wonderful system perpetuates).  The truth is, my patients have as much if not more at stake in this project.  They want me to succeed because that success will mean better care for them (and that I can stay in business and not move to New Zealand to wait for my Medicare Opt-Out period to end).  Many of them have joined me because they share my vision for care that is better for patients, better for doctors, and saves money.  Besides all that, anything I build won’t fly at all unless it works for them.

So I’ve started on this new project: the true collaborative health record.  It’s important to me because it enables me to run the system as well as possible.  I believe my model of care can only succeed if supported by an infrastructure to support it, but that with that infrastructure, it can become a viable alternative to the spend-care, sick care system both patients and doctors hate.

It’s official.  The road sign clearly welcomed me here.  I guess all business start-ups have to go through this town.

What?  No bravado?  No chest pounding about how my ideas will change health care while making patients smell as springtime fresh?  Nope.  None of that.  It’s hard to get excited about ideas when only money pays the bills.

Having now left the safe confines of my leftover earnings from my old practice, I am now supposed to be self-supporting.  Two big things have caused this to not go as smoothly as I have planned:

1. My construction took twice as long as I expected.
2. I have yet to find a computer system that doesn’t make me want to pound on my desk and wantonly overuse the word “inconceivable.”

A month behind on beginning to earn money hurts a lot, as does the extra cost of construction, but the computer problem has me beyond frustrated.  Why do they make medical records in which:

• Neither I nor my nurse could figure out how to put in vital signs
• You can’t print out a letter with lab results
• You can’t enter a “historic” or “handwritten” prescription to document it was given
• There is no flowsheet in which to enter lab results (we are 4 for 4 on that one)
• There is no way to attach external documents
• There is no marital status of “single,” but there is “polygamous”?

I guess I am just a perfectionist, expecting everything from a record, but why do I have to settle for an EMR by choosing the one that is “the least aggravating?”  But this is what I’ve had to do, and today I was entering data and getting distracted by my frustration, thinking bad thoughts about software engineers and fantasizing about building my own system?  Before anyone tells me I should do just that, let me point out three things:

1. I don’t have the time.
2. I don’t have the money.
3. When feeling insecure about how I run one business, the solution isn’t to add another new business.

So this is hell.  I am doing my best to be satisfied with my “minimum viable product,” meaning that I am satisfied with putting out care that my patients are happy about (which they are) even if I am frustrated with the process of giving that care.  I need to grow, but the computers are making it very difficult.  I’ve had lots of suggestions thrown my direction, ideas of how I may solve my problem.  It’s probably just going to take time.  I am learning patience.  I am learning humility.  I will be stronger for the lessons I am learning.

I’ve even considered trying to raise money as a “health care start-up.”  I’ve looked into small business incubators (although, being in Hell, the idea of an incubator isn’t that appealing).  I could have people buy bricks.  I could sell autographed pictures of llamas (although I’d have to find a llama who can write first).  I could engrave the name of supporters on my “humongous handicap ramp of awesomeness.”

I’m waiting for the Riders of Rohan to appear on the hill, but so far they haven’t come.

Come on, Theoden.  I’m counting on you.  I just hope you’re not a software engineer.

Dear HIPAA:

I’m sure you get a lot of hate mail, especially from folks in my profession, so when you got this letter from me you probably assumed it was more of the same.  Let me reassure you: I am not one of those docs.  I do think patient privacy is important, and actually found you quite useful when facing unwanted probing questions from family members.  I believe the only way for patients to really open up to docs like me is to have a culture of respect for privacy, and you are a large part of that trust I can enjoy.  Yeah, there was trust before you were around, but that was before the internet, and before people used words like “social media,” and “data mining.”

But there have been things done in your name that I’ve recently come in contact with that make me conclude that either A: you are very much misunderstood, or B: you have a really dark side.

The first situation has to do with my newfound infatuation with communication in health care.  I believe that the tools afforded by the internet tubes could really change care for the better; in fact, I think they could allow systems of care that could totally disrupt our malignant sick-care, cash-care system.  I’ve found ways to communicate that you would approve of and have shared them with my patients.  They love it.  They love to connect with me while they have problems instead of paying for a visit and waiting in the office for a few hours for my help.  It’s been really fun to see their enthusiasm.

So what’s the problem?  It’s the doctors.  Even though this communication system would allow them to give better care, allow us to collaborate without hassle, and bring back some of that “doctor’s dining room” collegiality we’ve lost, these doctors are afraid to use it.  No, they are terrified.  Asking them for their email address is taken to be as brash as asking for their credit card number or their wife’s cell phone number.  I can see it on their faces: they picture headlines about doctors being sued millions for stolen laptops with patient files on them.  They hear the ravings at conference warning against the use of email for patient communication and the perils of using social media.  They see me as a temptress trying to lure them into the dangerous online neighborhood, full of federal agents waiting to pounce, lawyers eager to sue, and journalists anxious to put their photo on the front page of the paper.  OK, well, maybe the electronic version of the paper, but I was using a figure of speech.  Nobody reads the paper version any more.

The point is, my patients are getting worse care because of this fear.  I can’t send a message to consultants explaining why I am sending them the patient, so they make a guess and order extra tests.  I can’t put my thoughts together with a colleague on a mutual patient with a difficult problem.  All I get are forms to be filled out and faxed (although who knows where that fax as been?) and faxed notes with bits of information hidden under layer upon layer of E/M coding bubble-wrap.  It’s worthless.  It’s not communication at all, and it hurts my patients.

The second circumstance is more personal.  When I got the boo…left my practice last fall, I left behind 18 years worth of patient records.  Those are records documenting my decisions, my though processes, and my care of my patients.  Sure, they weren’t the prettiest notes around, but they represented a lot of thought and care.  As I was heading out on my last day at the practice I was notified that, upon leaving, I would not have access to these records.  It seems that, despite the fact that these are records I personally wrote about my own interaction with my patients, I would be violating you if I looked at them.  This information is the property of the practice, and allowing someone who was no longer a member of that practice to view them would bring down swat teams of federal agents within seconds.  This, at least, was the opinion of the practice’s legal counsel.

Having just gone through a divorce, I had no desire to argue with my ex’s lawyer, so I took it like a soldier.  I figured I’d just get information sent to me when I needed it.  In fact, I came upon another very secure solution to make this process easy and efficient.  But alas, the ex wanted nothing to do with my newfangled way of doing things, instead resorting to the high-risk behavior of faxing records (who knows where those fax machines have been?).  As fate would have it, our faxes didn’t get along well, causing them to inundate me with duplicate faxes, a veritable Torrent of TIF’s, a plethora of PDF’s.  This has made it next to impossible to get records on my patients, making care of them much, much harder.  These are not just any records, they are my records of my care for my patients! 

Say it ain’t so, HIPAA!

Do you really keep doctors from their records?  Do you really keep patients from good care?  Or is this simply a culture of paranoia that has propagated on ignorant doctors by fear-mongering lawyers, lecturers, and office administrators happy for the chance to intimidate the consumate intimidators?  Yes, flaunting medical records to anyone who throws you beads is a bad practice that will lead to regret in the morning, but preventing communication kills.  I thought better of you.  I thought you were there to protect people from careless talk, from snooping employers, and from front-office gossips.

So, I ask, is it you or is it those who wish to slander your name?  Are you a tool to protect, or are you a gag in the mouth of good care?

I anxiously await your reply.

Dr. Rob

“Patient engagement.”

What is “Patient Engagement?”  It sounds like a season of “The Bachelor” where a doctor dates hot patients.  It wouldn’t surprise me if it was. After all, patient engagement is hot; it’s the new buzz phrase for health wonks.  There was a even an entire day at the recent HIMSS conference dedicated to “Patient engagement.”  I think the next season of “The Bachelor” should feature a wonk at HIMSS looking for a wonkettes to love.

Here’s how the Internets define “Patient engagement”:

• The Get Well Network (with a smiley face) calls it: “A national health priority and a core strategy for performance improvement.”
• Leonard Kish refers to it as “The Blockbuster Drug of the Century” (it narrowly beat out Viagra) – HT to Dave Chase.
• Steve Wilkins refers to it as “The Holy Grail of Health Care” (it also narrowly beat out Viagra) – HT to Kevin MD.
• On the HIMSS Patient Engagement Day, the following topics were discussed:
  • How to make Patients Your Partners in Satisfying Meaningful Use Stage 2 Objectives; Case Studies in Patient Engagement, session #64;
  • Review Business Cases for Implementing a Patient-Centered Communication Strategy and Building Patient 2.0, session #84;: and
  • Engaging People in Health Through Consumer-Facing Devices and Tools, session #102.

So then, “patient engagement” is:

• a strategy
• a drug
• a grail (although I already have a grail)
• a “meaningful use” objective
• something that requires a business case
• something that requires “consumer-facing devices and tools” (I already have one of those too).

I hope that clears things up.

So why am I being so snarky about this?  Why make fun of a term used by many people I trust and respect?  I was recently discussing my ideas on a communication-centered medical record with a colleague.  At the end of my pontification, my friend agreed, saying: “you are right; communication is an important part of health care.”  I surprised him by disagreeing.  Communication isn’t important to health care, communication is health care. Care is not a static thing, it is the transaction of ideas. The patient tells me what is going on, I listen, I share my thoughts with the patient (and other providers), and the patient uses the result of this transaction for their own benefit.

But our fine system doesn’t embrace this definition.  We indict ourselves when we talk about “patient engagement” as if it’s a goal, as it reveals the current state of disengagement .  Patients are not the center of care.  Patients are a source of data so doctors can get “meaningful use” checks.  Patients are the proof that our organizations are accountable.  Patients live in our “patient-centered” medical homes.

Replacing patients as the object of our attention (and affection) is our dear friend, the medical record.  We faun over medical records.  Companies earn epic profits from medical records.  We hold huge conferences to celebrate medical records.  We charge patients money to get to see their own medical records.  We even build special booths (portals) where patients are allowed to peer in through a peep hole and see parts of their medical records.

This is why I’ve had such a hard time finding a record system for my new practice.  I want my IT to center on patients, but medical record systems are self-absorbed.  They are an end in themselves.  They are all about making records, not engaging patients.  They are for the storage of ideas, not the transfer of them.  Asking medical records to engage patients is like asking a dictionary to tell a story.

The problem is, documentation has taken over health care.  Just as the practice of a religion can overshadow its purpose: the search for God, documentation chokes out the heart of health care: the communication of ideas .  It did this because we are paid to document, not communicate.  Communication takes time and it is not reimbursed.  Communication prevents unnecessary care, which is a revenue stream.  Communication eliminates waste, and waste is food that feeds the system, the bricks that build the wings to hospitals, the revenue source that pads IT budgets.

So what’s a doctor to do?  I’m not sure.  I am still looking for a solution that will meet the central goals of my practice:

• Communication – health care is a hassle,  with communication relegated to the exam room.  I want care to be easily accessible for my patients,using IT in one of its strongest areas: tools for easy communication.
• Collaboration – the patient should be engaged, but in a two-way relationship.  This means they not only should have access to their records, they should contribute to those records.
• Organization – I want a calendar documenting visits, symptoms, problems, medications, past and future events in each patient’s record.  I also want a task-management system I share with patients to make sure care gets done.
• Education – I want to practice high-quality medicine, care that is informed by good information and the best evidence.  Why not do a yearly stress test?  There’s evidence for that.  Why not use antibiotics for sinus infections?  There’s evidence there.  Why use an ACE inhibitor to control the blood pressure?  I need to be able to support my recommendations with data, not just “because the doctor said so.”

The point of all of this is the moving of medicine from an industry where money is milked from disease to a communications network where diseases are prevented.  ”Patient engagement” that is done to the patient for the sake of the doctor or hospital is a sham.  Engagement is about interaction, listening, and learning in relationship to another person.  Engagement is not a strategy, it is care.

If only I could find the tools to make this happen.

It’s been a month since I started my new practice.  We are up to nearly 150 patients now, and aside from the cost to renovate my building, our revenue has already surpassed our spending.  The reason this is possible is that a cash-pay practice in which 100% of income is paid up front has an incredibly low overhead.  My admitted ineptitude at financial complexity has forced me to simplify our finances as much as possible.  This means that the accounting is “so simple even a doctor can do it,” which means I don’t need any front-office support staff.  I don’t send out bills because nobody owes me anything.  It’s just me and my nurse, focusing our energy on jury-rigging a computerized record so we can give good care.

Our attention to care has not gone unnoticed.  Yesterday I got a call from a local TV news reporter who wanted to do a story on what I am doing.  Apparently she heard rumor “from someone who was in the hospital.”  I was the talk of the newsroom, yet I’ve hardly done any marketing; in fact, I am trying to limit the rate of our growth so I can focus on building a system that won’t collapse under a higher patient volume.  I explained this to the disappointed reporter why I was not interested in the interview by telling her that I left my old practice because I needed to get off of the hamster wheel of healthcare; the last thing I want to do now is to build my own hamster wheel.

I’ve also gotten interest from a place I didn’t expect: local specialists.  I always thought what I am doing applies only to primary care, as it is hard to do a monthly fee for the procedure-oriented specialties.  But as the enthusiasm for my new type of practice grows in the community, it may spur a boom in cash-paying patients.  Why?  One of the provisions in the Accountable Care Act (ACA) is that small businesses (with over 50 employees) who want to avoid the penalty for not having insurance can opt to contract with a direct-care physician like myself in conjunction with a high-deductible health care plan.  Even though I have made no effort to attract such interest, I’ve already been approached by 2 businesses of 100 employees to make such an arrangement.  Again, I turned the offer down for now, saying I am quite interested, but would only do so when my practice was ready.  But the fact that this happened while I am doing my to best avoid attracting such attention suggests to me that the desire for this is very intense in the small business community.  This makes sense, as they don’t want to pay the fines, but also don’t want to pay the exorbitant cost of standard insurance, and so would jump at any other option.

The end result is a potentially large influx of patients who are basically self-pay.  The specialists, who see me lowering my overhead significantly by taking cash payment up-front, see the same opportunity for their practices.  The hitch for them is that they are not allowed to give discounts to self-pay patients that they are not also giving to Medicare patients.  Yes, it is illegal for a Medicare provider to give a discount to non-Medicare patients who cannot afford the cost.  There are ways around this rule, and I hope to work out something for my specialist colleagues so they can give significant discounts in exchange for cash up front (which is, by the way, the same logic that the labs use to give the enormous discounts I am offering to my patients on lab services).  I have had multiple specialists show very high interest in such an arrangement.  I’ll fill you in as this develops.

This seems quite ironic to me – a sort of “trickle-up economics,” where I am spreading the benefit of offering discounted care in exchange for cash to the higher-paid specialists.  It is a win-win-win arrangement, though, as the specialists benefit from reducing their overhead while getting guaranteed payment, I benefit by increasing the value of my type of practice even more to my patients, and the patient benefits by getting cheaper care.  This, of course, raises the likelihood that more businesses will opt for this payment model, and the movement gains momentum. Who loses?  The “increased overhead” comes in the form of the front-office staff doing billing, coding, and collections.  This is the staff my simple-minded approach to finances has heretofore avoided, and hopes to continue avoiding.

I may be completely wrong in this, as it may not consider other factors (which wouldn’t surprise me), but I am not wrong about the intense interest I see in what I am doing.  It is palpable.  When I spoke at HIMSS over the weekend (ironically as keynote for a pre-conference targeted at large health systems building ACO’s), the reception was remarkably positive.  My message of simplicity is falling, apparently, on very fertile soil.  Did they realize the implication of “cost savings” being the need for less employees and the to downsize their business?  I took great pains to emphasize the point, yet the reception was vigorously positive.

I suppose little should surprise me, in a world where the have-less’s could have their abundance trickle up to the have-mores.  Who knows, maybe people will even pay attention to the economic wisdom of a doctor with an accounting impediment.

Nah.  That’s ridiculous.

For the record: I am a geek.  I love technology.  I adopted EMR when all the cool kids were using paper.  Instead of loitering in the “in” doctors lounge making eyes at the nurses, I was writing clinical content and making my care more efficient.  I was getting “meaningful use” out of my EMR even when nobody paid me to do it.  

But now who’s laughing?  While they are slaving away trying to get their “meaningful use” checks, I’ve moved on to greener pastures, laughing at their sorry butts!  It’s just like my mom promised it would be.  Thanks mom.

Really, for the record, I am not so much a technology fan as a “systems” guy.  I like finding the right tool for the job, building systems that make it easier to do what I want, and technology is perfect for that job.  I am not so much a fan of technology, but what technology can do.  Technology is not the goal, it is the best tool to reach many of my goals.  There are two things that measure the effectiveness of a tool:

1. Is the tool the right one for the job?
2. Is the person using the tool properly?

So, when answering the question I posed at the end of my last post, what constitutes a “good” EMR, I have to use these criteria.

How is technology the right tool for the job?  The job I seek to do is not what EMR’s are designed for: documenting health care.  I want a tool to help me give care.  I can afford to focus on giving better care since I am no longer paid to document, which is what the health care system demands of doctors.  I spent the past 16 years using a documentation tool for care, which is definitely a mismatch.

What then would a care tool look like?  Here are the things I think are most important for good care:

1.  Communication over Documentation

While data gets all the attention of IT vendors, health executives, and government drones, it is the communication of that data that constitutes good care.  One of my first goals in my new practice is to use whatever tools possible to enable that communication.  Standard health care only allows communication in the exam room (although many patients would say that doctors are so focused on documentation that they don’t listen there either).  Between office visits there is virtual silence from the patient, as if their life is not happening during that time.

I’ve considered making bumper stickers that say: “My doctor answers my email” or “My doctor answers the phone,” with my logo and web address underneath.  This is effective because of the insinuated truth that most doctors don’t do either.  The system dictates this, but good care says otherwise.  My patients have been delighted when I answer questions, view the spreadsheets they fill out, and interact with them on a daily basis.  It’s communication, and tech makes it much easier.

Documentation is OK, as long as that documentation centers on the communication of data, not just the data itself.

Yet even I use the term “medical record,” which refers to a static collection of data rather than a tool to allow that data to be used well.  Any good health IT system must not simply document the communication, but must enable that communication as to happen easily as possible.  This means both getting information from my patients and putting it into their hands.  This is why another central goal of my practice is to give patients access to their records.  Too much of patient care is done blindly, not knowing what care has been done, relying on the patient to re-recite their medical history.  With the proliferation of mobile technology, my patients can bring their medical record with them wherever they go.  This, in turn, enables better communication with other providers.

2.  Organization of Data

Walking around with a computerized stack of paper, however, is not all that my patients need; they need the information to be organized.  This is another of the strengths of IT.  An astute commenter on my last post gave a link to a TED talk on the beauty of data visualization, which shows how organizing and presenting data in the right way can make dry data tell rich stories.  I want an EMR that shows me a timeline of the patient tagged with their symptoms, medications, lab results, vital signs, and any other pertinent data I want to see.  What is the relationship of exercise to your depression?  Did that back pain start after you added that medication?

The point of organization is to see through the extraneous to see the meaningful.  It is, in essence, another part of communication.  As I listen to a patient’s story, I ask questions and bring out important details they may have missed, and ignoring that which I know is not significant.  This is what makes a good diagnostician, and the ability to this with the volumes of patient data is what would allow IT to improve care.

3.  Collaboration, not Ownership

The world of health IT is obsessed with something called “data ownership.”  This is kind of crazy, as data is information, and information is fluid.  How do you “own” information?  If I learn a fact, do I “own it?”  If I possess a book, does that make me the owner of its ideas?  The wonderful world of HIPAA and the threat of identity theft has bolstered the cause of “ownership.”  Unfortunately, communication of ideas is diametrically opposed to this concept.  IT must not be about building walled gardens of data, but about collaborating with that data for the sake of patient care.

I first heard of the term, collaborative health record from Dave Chase (the guy who first told me about my kind of practice), and I really like the concept.  The idea is that the ideal patient record is a collaboration between the patient and the caretakers.  Patients know things I don’t: what meds they’ve been taking, how they feel, whether they are married, are smoking, or if they had measles as a child.  In fact, if you look at a typical note in a patient chart, the majority of the information is originally “owned” by the patient.  So why not let them take care of those parts of the record?  Why not let them update when they’ve been to a specialist and had their medication changed?  Better yet, why not have the specialist take part in this too, collaborating to make sure the patient got the message correctly?

Why, in fact, do I need to re-create what the patient could do better than me?  Why not just look at what they’ve done instead of transcribing it into “my” record?

This sounds suspiciously like a wiki.  What resource on the internet gives useful (albeit sometimes inaccurate) information in a format that elementary school students understand?  Wikipedia.  Isn’t this a better way to organize patient data than a typical EMR?

4. Easy Does It

In considering what I need from IT to give patient care, there is one more thing I need – something that is clearly lacking in most EMR systems: ease of use.  I should have seen the writing on the wall when my EMR vendor insisted I pay for 4 days of onsite training before I could use their system.  I don’t want to learn a new language, and my patients want it even less.  Just as a medication a patient cannot afford is useless, a technology a patient won’t use is also useless.  Tech can go either way on this: either making difficult tasks easy or making simple things complicated.  This is where Steve Jobs was right: design simplicity.

I don’t want my patients to have a separate log-in for each part of their care.  I want a single sign-in and a uniform experience.  I want an app that they press which pops up options to “refill my meds,” “contact my doctor,” “update my record,” and “look up a result.”  I don’t want them to need to own certain software or download files.  It’s got to be easy and well-designed.

Putting it together

So in thinking about this wish list, it occurred to me that there is one company that could deliver all of the goods here: Google.  Apple and Microsoft have many of the same tools, but they are far more proprietary in their approach.  If I share a spreadsheet with a patient, I don’t want to have to worry they own Excel.  If I want to do a video chat, I don’t want to have to consider if they’ve got a device that can do FaceTime.  Google does email, spreadsheets, video chat, groups, web pages, organizes data, and has lots of cat videos to boot.  And all of these services are easy to use and free.  Most of them are free.

So should Google get back into health IT?  Didn’t they already try health IT and fail?  Ah, but it’s not just having the right tool that is important, it’s knowing how to use it.

So, Google, if you really are interested in changing the world for the better, you know where to find me.  I suppose I’d be willing to talk.

It feels like part of me is dying.  I am losing something that has been a part of me for nearly 20 years.

I bought in to the idea of electronic records in the early 90′s and was enthusiastic enough to implement in my practice in 1996.  My initial motivation was selfish: I am not an organized person by nature (distractible, in case you forgot), and computers do much of the heavy lifting in organization.  I saw electronics as an excellent organization system for documents.  Templates could make documentation quicker and I could keep better track of labs and x-rays.  I could give better care, and that was a good enough reason to use it.

But the EMR product we bought, as it came out of the box, was sorely lacking.  Instead of making it easier to document I had to use templates generated by someone else – someone who obviously was not a physician (engineers, I later discovered).  So we made a compromise: since it was easier to format printed data, we took that data and made a printed template.  We would then write in the vitals, dictate our history, circle options on the review of systems and physical exam, and dictate our plan.  That written record would then be put into the EMR as a finished note by the transcriptionist.  It was a strange way to do things, but it was far more efficient.  At the first user group meeting (after 9 months of use), we were using the product better than anyone else.

For us, the bottom line was not computers, it was patient care.  Our record system was a tool to let us eliminate inefficiency and focus more on care quality.  We were spending less time and doing a better job.  Within two years I was elected president of the national user group for our EMR and became an evangelist for the benefits of computerized records.  I was proof that doctors could adopt technology and not just survive, but thrive.  My peers thought I was eccentric (shocking) and I made few converts.

There is one moment during those first years I will never forget: one of the “aha” moments in my life, a time when things snapped into focus.  I was trying to figure out how to milk more efficiency out of our system and was thinking about using the data for more than just documentation.  My zeal for process improvement earned me the right to be one of the first to have access to the content customization tool for the EMR and I quickly produced content that was very popular (our vendor wisely gave the tool only if we were willing to share our creations).  While I was thinking about ways to improve efficiency, I thought about all of the data at my disposal.  I had years of structured data on thousands of patients: vitals, lab results, medications, problem lists, and other pertinent patient information.  Whoa!  What if I could put all that data together and really coordinate care?  What if I could, instead of using the EMR as a fancy word processing program, I used the data I collected to improve care?  It was like moving from two to three dimensions.  Nobody was talking about this at all; the focus was entirely on documentation, not data.  I remember the room I was in when the thought it me.

Armed with my new vision of EMR, I called my vendor (I was, after all, the president of the user group) and made a pitch to the engineers and company executives. I was clearly one of the top users of their product, but I felt like I was only using a fraction of the product’s potential.  Yet I was in private practice and so had no access to the resources to tap that potential.  I proposed that the vendor fund my effort to make the product work on all cylinders, to really show what it could do if its full potential was harnessed. The investment wouldn’t be much, since we were still a small practice.  In exchange for their support, they could use what I made to show the world what really good care looked like.  I expected astonished gasps from the other end of the line, but was met by silence.  Eventually one of the executives told me that the product was already being used to its full potential.  They did, after all, have an E/M coding advisor.

Frustrated at their blindness to my insight, I set out to prove them wrong, spending countless hours wrestling with the system to make it do what I want: improve the care I was giving without taking extra time.  The systems I developed helped us offer better care (double the national average on colonoscopy, pneumococcal vaccine, A1c monitoring), and still be in the top 10% of income for primary care.  This accomplishment earned us the Davies Award from HIMSS, and earned me a permanent spot on the EMR speaking circuit.  Still, I was never really satisfied with the care I gave, and always looked for ways to do it better.

Unfortunately, the increasing popularity of EMR caused increased focus from the government.  PQRI, NCQA, HIPAA, and CCHIT all took focus of our vendor from clinical development, instead focusing on regulatory requirements.  When the HITECH act passed I was still (delusionally) optimistic that the focus would eventually turn to patient care.  But the last update I saw on the product I bought in 1996 showed the truth: the product was certified for “meaningful use,” but it was bad. Really bad.  We even nicknamed it “Vista.”  Previously simple tasks were difficult, and data was harder to use, and was not moving at all toward better patient care.

My inability to accept mediocre care (and my obnoxious obsession with improving it, from my partners’ perspective) eventually drove me from the world of meaningful use and E/M coding to my current home: a practice that accepts only monthly payments between $30 and $60 a month in exchange for an undiluted attention to patient care.  Without the overhead caused by the ridiculous complexity of our payment system, I can finally realize my dream of showing the world what good care actually looks like.

But here’s the hitch: EMR has never left the world of note generation.  Yes, it does submit data so the doctor can get the check for (ironically) achieving “meaningful use,” but that data is still very hard to actually use to improve care.  My attempts at using other EMR products to accomplish my goal have proven to me once and for all that to truly give good care I’d have to abandon EMR as I knew it.  I’ve got to look beyond EMR to something better, more focused on the patient and less on the payment.  But it’s really been a hard search.  I know what I want to do, but the road to that goal is not yet evident.

So what do I think really good electronic records should look like?  I’m up to 1144 words now, so that will have to wait for a future post.  Instead, let me take this moment to throw a flower on the grave of the EMR enthusiast.  It’s been quite a ride.  I don’t join those who look back to the “good old days” of paper records (It’s like longing for the “good old days” before indoor plumbing).  No, I still look to use technology to make my care better; it just won’t include EMR’s in the form they are now.  In truth, it’s never been about computers; it’s about the person sitting across from me: the one who is putting their life in my hands.  Perhaps the death of this evangelist can prevent other deaths, the real ones.