Thank you, my patients for all you have done for me. Thank you for the encouragement and support. Thank you for believing in me enough to join me in this crazy new way to do health care. Thank you for giving me the honor of being the one you call “my doctor.”
Your trust motivates me to work harder to justify that faith in me – a faith I often don’t have and, one I certainly wouldn’t have without you. I hope and pray this holiday season is a blessing to you. May you find peace in this time of year so often without peace.
May you also have a happy and healthy new year. May you stay out of the ER, away from the hospital and, yes, away from doctors. May you have no need for lab tests, procedures, x-rays and medications (and if you must have medications may they be very cheap.)
If, however, you do get sick, remember that I am here to help you get well, feel better or avoid getting any worse. And if I cannot do any of these, I will still be there to stand by your side through the hard times, and to offer whatever comfort I can give. Doing these things is what it means to me when you call me “my doctor.” It is why that is such an honor.
Again, thank you for all you do for me. God bless you.
Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind),where an earlier version of this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.
Filed Under: Physicians
Tagged: Patients, Physicians, practice of medicine, primary care, Rob Lamberts
Dec 8, 2013
He seemed a bit grumpy when he came into the office. I am used to the picture: male in his early to mid-forties, with wife by his side leading him into the office to “finally get taken care of” by the doctor. Usually the woman has a disgusted expression on her face as he looks like a boy forced to spend his afternoon in a fabric store with his mother. My office is the last place he wants to be.
He let himself down on the couch across from my desk with a wince, belying the back pain that brought him here. He looks around at my office, which is not only a place he didn’t expect to be, but not what he expects a doctor’s office to look like. First there’s the sofa he is sitting on, which is where my patients spend most of their time during their visits. Then there is my guitar just behind me. He and his wife comment on how their daughter would love the fact that I have a guitar, as she is into acoustic guitar music. Then there’s me, wearing jeans and an untucked button-up shirt, sitting back in my chair and chatting like an ordinary person. He seems intrigued.
He owns a business, which is a service type business like mine. Like me, he and his wife choose to do things differently, charging less for folks who can’t afford it. I chat with him about the stress and strain of owning and running a small business, pointing out how his choice is similar to mine.
He had actually suggested coming to me after he had seen me on television, but obviously had initial doubts as to the accuracy of the report. Spin happens. But as we talk, there is much to find in common, and he warms up. His shoulders relax, he sits back on the couch, and forgets he’s in the doctor’s office.
Continue reading “Target Demographic”
Filed Under: Physicians
Tagged: direct primary care, doctor/ patient relationship, Patient-centered care, Patients, practice management, primary care, Rob Lamberts, Small Business
Oct 11, 2013
So, the question has been raised: why am I doing this? Why re-invent the EMR wheel? What is so different about what I am doing that makes it necessary to go through such a painful venture? I ask myself this same question, actually.
Here’s my answer to that question:
What medical records offer:
High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.
What I need:
No focus on billing codes, instead a focus on work-flow.
What medical records offer:
Complex documentation to satisfy the E/M coding rules put forth by CMS.This assures physicians are not at risk of fraud allegation should there be an audit. It results in massive over-documentation and obfuscation of pertinent information.
What I need:
Documentation should only be for the sake of patient care. I need to know what went on and what the patient’s story is at any given time.
What medical records offer:
Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)
What I need:
Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not. My goal is to keep them out of the office because they are healthy.
What medical records offer:
Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.
Continue reading “What I Need”
Filed Under: Tech, THCB
Tagged: direct primary care, EHR, practice management, primary care, Rob Lamberts
Aug 29, 2013
While hard at work at building a new practice and (in the eyes of some) on my insanely misguided effort to build a medical record, I’ve been thinking. Dangerous thing to do, you know. It can lead to scary things like ideas, creativity, and change. I know, I should be satisfied with the usual mental vacuum state, but I’ve found it a very hard habit to kick. Perhaps there’s a 12-step group for folks with ideas they can’t suppress.
Anyway, my thoughts have centered around explaining what I am doing with all of the my time and energy, and, more importantly, why I am doing all that stuff that keeps me from writing about important things like body odor, accordions, and toddlers with flame-throwers. I’ve really strayed from the good ol’ days, haven’t I? The problem is, I’ve grown so accustomed to my nerd persona that I end up giving explanations that are harder to understand. To combat this, I’ve decided to employ a technique I learned from my formative years: stories with pictures. My hope is that, through the use of my incredible drawing talent I will not only explain things faster (saving 1000 words per picture), but prevent my readers from falling, as they often do, into a confused slumber.
So, here goes.
Adventures in Health Care: Part 1 – The Participants
This is a patient. Let’s call him “Chuck.” Chuck is not really a “patient,” he’s a person. Many doctors believe that people like Chuck don’t exist outside of their role as “patients,” but this has been proven false (thanks to the tireless work of Oprah and ePatient Dave). But since this story is about Chuck’s wacky adventures in health care, we will mainly think of Chuck in his role of “patient.”
Why are people like Chuck called “patients?” Some people think it’s to put them in their necessary subservient place in the system. I think it’s just to be ironic.
Chuck is a generally healthy guy, but occasionally he does get sick. He also worries about getting sick in the future, and want’s to keep himself as healthy as possible. This is when he uses the health care system, and when he is forced to be “patient.”
Continue reading “Adventures in Medicine”
Filed Under: THCB, The Insider's Guide To Health Care
Tagged: Patients, practice management, primary care, Rob Lamberts
Aug 20, 2013
My mom is great.
Unfortunately, like most mothers, she relishes telling funny (usually embarrassing) stories about us kids. I, unfortunately, seem to be the subject of the vast majority of those stories. But my big brother gets the leading role in one I will now tell. I guess it’s a small way to get back at him for…well, for lots of stuff. One day he came home from school all excited (unusual for my half-vulcan brother). ”Mom! Mom! I learned how to swim today!” he said. ”Oh?” my mother answered, not sure how and where he learned this new skill. Bill got a very pleased expression as he explained, “Steven V. taught me on the bus!” This is where my mother guffaws and my father chuckles and we kids look at each other with the well-worn “when will this story get old?” expression. He’s probably making that expression at his computer right now.
But the naïveté expressed by my brother at the nature of learning how to swim is similar to my confidence going into this project. Certainly it helps to know you can’t breathe underwater, and that swimming in a suit of armor is a bad idea, but this knowledge does not substitute for the first-hand experience of keeping afloat while the water seems to be trying to drown you. Similarly, I could read books, make a business plan, and impress people with my thought and insights, but that does not substitute for the first-hand experience of building a new business from scratch. It does nothing to keep me financially afloat while unseen forces try to pull me under.
Which brings me to my current situation. Would I have taken the plunge had I known what it’s taken up until now? It has been hard.
I hesitate to write about this, because:
- I hate to sound whiney.
- I don’t want people to worry that things are worse than they are. Especially my patients.
- I don’t want to get a lot of advice from well-meaning people who don’t know the details of my situation.
But I want to give a realistic picture of what this journey is like, not just throw you the vaporware version. Besides, my world right now has significant stress and pressures that I didn’t anticipate.
The first sign of trouble came very early, in the renovation of my office. My goal was to start seeing patients in mid-December, and officially opening around the first of the year. Unfortunately, the office wasn’t ready until February 6th, and the construction cost twice what I expected. For those who can’t see the implication: I spent more money and lost a month of earning it. More money out, less money in. Maybe swimming’s a little harder than Steven said it was.
Then came the EMR debacle.
Of the areas I was most sure of, my ability to use computers to improve care was at the top. After all, I had won national awards and much acclaim for my use of electronic records to improve care. Two months and five EMR products later, I was beginning to see just how far the health IT industry had moved away from patient care. I din’t know what to do; I was at an impasse. Each system I tried either lacked some basic element of organization I required (such as management of outside documents) or was unable to generate anything but the voluminous documentation which succeeds only in two areas: getting physicians paid and hiding useful clinical information.
Continue reading “The Good Doctor Calls For Backup”
Filed Under: THCB
Tagged: practice management, primary care, Rob Lamberts, the business of health care
Aug 15, 2013
A patient calls or emails me with a problem. I talk with them over the course of a few days, using whatever form of communication works best. Eventually, they need to come to the office to be seen – either for something needing to be done in-person (examination, procedure, or lab test), or because of the advantages of face-to-face communication. At the visit, I not only deal with one problem, but there are other issues needing to be addressed. Finally, after the visit, follow-up on the problem continues until it is either resolved, or at least is not causing much trouble.
So how do I document that?
In the past I would’ve had a clear structure for the “office visit” and separate “encounters” for the documentation of the communication done outside of the office. The latter would be done largely with narrative of the conversation, and some direct quotes from the patient. The former, the “office visit” would include:
- A re-telling of the story of the “chief complaint” and what’s been happening that caused this encounter to be necessary.
- A sifting through other symptoms and past-problems to see if there is any information hidden there that may be useful.
- A documentation of past problems (already in the record) to support the thought process documented later in the visit.
- An overview of the physical exam, again to support the decisions made as a result of the visit.
- A discussion of my thoughts on what I think is going on.
- A telling of my plan on how to deal with this.
- A list of any advice given, tests ordered, medications changed, prescriptions written, and follow-up as the details of that plan.
- A signature at the end, attesting to the validity of what is contained in the note.
But here’s the problem: it’s not real. I don’t make all of my decisions based on the visit, and the patient’s story is not limited to what they tell me. Details may be left out because they are forgotten, questions aren’t asked, or things just haven’t happened yet. This signed and sealed unit of care, represented as a full story, actually represents only fragments of the story, of many stories actually, and only as a moment on the continuum of the patient’s care.
Continue reading “The Office Visit Revisited”
Filed Under: Tech, THCB
Tagged: EHR, Patients, practice management, primary care, Rob Lamberts
Jul 21, 2013
It has been nearly 6 months since I started my new practice, since I took the jump (or, more accurately, was pushed off the ledge) into a brave new world. It seems very distant, like I should get Shirley MacLaine or Gwyneth Paltrow to help me channel my old sad self. It is tempting.
I have a vague recollection, a memory shrouded in mist, where I pondered what seemed like a radical question: What would a health record look like if my only concern was patient care? This was a radical question because in my previous life I was an electronic health record aficionado. I was good at EMR, which meant that I was really good at finding work-arounds:
- How can I work around the requirements for bloated documents and produce records that are actually useful? The goal of records in that previous life was to justify billing, not for patient care.
- How can I work around the financial necessity to keep my schedule unreasonably full and keep my visits unreasonably short and still give good care?
- How can I work around the fact that I am paid better when people are sick and still try to keep them healthy?
- How can I work around the increased amount of my time devoted to qualifying for “meaningful use” and still give care that is meaningful?
Computers were all about automating the drudgery, organizing the chaos, and carving out a sliver of time so I could spend the extra minutes needed to give the care I wanted to give. I was using them to give good care despite the real nature of the medical record: a vehicle for billing.
But that was my past life. Now I no longer have to worry about a Medicare audit (and the looming threat of an accusation of “fraud” for simply not obeying the impossible documentation rules). I no longer have to keep my office full and my patients sick enough to pay the bills. I am actually rewarded for handing problems early, for communicating well, and for keeping patients healthy and happy, as it keeps them paying the monthly subscription fee.
Ironically, in asking the question, what would a health record look like if my only concern was patient care, I was really asking the question: What does “meaningful use” of the record really look like?
Now this question is no longer a hypothetical; it is real.
Continue reading “Really Meaningful Use”
Filed Under: Tech, THCB
Tagged: EHR, Meaningful Use, practice management, primary care, Rob Lamberts
Jul 15, 2013
Hi. It’s me again. No, I’ve been doing fine; my writing slow-down is not due to calamity, catastrophe, apostrophe, or even syndactyly. I’ve been working hard, working like a dog.
So, what’s been so all-consuming that I can’t sit down and write? My computer system. I know it may sound nerdy and lame, but I’ve been putting every ounce of my creative energy into building a system. It’s driven by two main things: trying to give the best care I can, and doing so while avoiding personal bankruptcy. Fear of the latter is strong motivation. So I’ve been pouring myself into this task like nothing I’ve done before. My goal is to build a system that will:
1. Organize information. My care will only be as good as the information I have. It should be presented in a way that gives me just the right amount of information, with the ability to get more when I need it.
2. Cope with the flood of incoming information. Take the piles of communications coming in and route it to the proper storage place, use the information to make decisions, communicate it with the patients, and decide on follow-up. This is an enormously difficult task.
3. Integrate with every communication tool possible. Most doctors don’t do this because they rely on office visits for income, and that hinders the care they give. Communication is care, and I want to have good communication that is enlightened by good information.
4. Create a shared medical record with my patients. I am convinced that my patients will get the best care if they have access to their information. But this needs to be done in a way that is both simple and secure. I want “one stop shopping” for people to communicate or look at their records.
5. Keep my books. I don’t want to go bankrupt and don’t want to go to jail for keeping disorganized books. It’s possible to get freed from the fear of Medicare audits, but not from IRS audits.
6. Organize the future. There are far too many missed opportunities for care. Integrated task-management (shared between patient and their care team) is my goal.
7. Grow with me. If I accomplish 1-6, my practice will grow. I don’t want that growth to outpace my system.
So far I’ve been focusing on 1, 2, and 5, with eyes on the rest. I’ve made great progress, but there’s much more needing to be done. My ultimate goal of this is to build working prototypes of both this practice model and the software that will enable it to be more than just a side-show, an alternative for doctors who want to escape. I believe that this is truly better care. It is focused on what the patient wants: to be healthy and to spend as little time thinking about their health care as possible. It’s working so far, but it can be much more than it is now.
Continue reading “Live From the Garage”
Filed Under: Physicians, THCB
Tagged: practice management, primary care, Rob Lamberts, software
Jul 7, 2013
Lately, my virtual inbox in our electronic medical record has seen a surge in requests for prescriptions for the vaccine against Herpes Zoster, shingles. This has made me think a lot about our responsibility as physicians to inform patients about the evidence behind our recommendations – but who informs the patients when doctors are kept out of the loop or put under pressure to prescribe without seeing the patient?
What has happened is that our local Rite-Aid Pharmacy started to give these shots, covered by many insurers, but still requiring a doctor’s prescription.
I cannot give the shots in my clinic, because as a Federally Qualified Health Center, we are reimbursed at a fixed rate. The shingles vaccine costs more for us to buy than we charge for an entire office visit. I used to have the discussion about the shot, and would give patients a prescription to take to the pharmacy if they wanted it.
The pharmacy can give the shot at a profit, because it is considered a medication, just like a bottle of Lipitor.
The new system creates a bit of a dilemma for me. I get a message through the pharmacy that the patient wants the shot, and I don’t have the opportunity to sit down and review the effectiveness, side effects and long-term efficacy according to the available evidence with the patient.
For example, the shingles vaccine only cuts the risk of getting shingles in half. This is about the same effectiveness as the flu vaccine, but far less than, say, the vaccine against smallpox, which has now been eradicated.
Most patients are very surprised to hear about the 50% efficacy when I catch up with them at some later date; so many health care interventions are portrayed as both completely effective and absolutely necessary.
I see my role as a primary care physician as a guide and resource for patients, who are bombarded with overly optimistic claims and recommendations by mass media, drug companies and retailers.
Continue reading “What the EMR Saw”
Filed Under: Physicians, Uncategorized
Tagged: Country Doctor, Interventions, Patients, Pharmacies, primary care, Reimbursement, Scope of Practice
Jul 3, 2013
Even before I launched my geriatric consultation practice, I found myself often pouring over another doctor’s outpatient notes, trying to explain to a patient what the other doctor was doing.
Sometimes these other doctors were specialists to whom I’d referred the patient. But often they were simply clinicians – either previous PCPs or currently involved specialists — whose involvement with the patient predated my own.
Not every patient had questions and concerns about what their other healthcare providers were saying, and doing, but a fair number of them did. And family caregivers, in particular, were often concerned that perhaps their older loved one hadn’t been getting the “right” medical care.
These are, in truth, legitimate concerns patients have. In a busy outpatient setting, doctors often don’t have the time to explain the assessment and plan to a patient and family. And in many cases, the care that clinicians provide may not correspond to best practice guidelines – if applicable to the situation – or to the patient’s preferences and values.
So if you are a concerned patient or family member, and you’re not entirely sure about the medical care you’re getting, what to do?
- Look up the provider’s quality ratings online, through a government, non-profit, or other website?
- Figure that the ACO or payer is on top of it, now that we are moving to pay-for-quality and fee-for-value?
- See what other patients have said about the provider’s care?
- See how many doctors are referring to the provider in question, and assume that if many doctors refer to this clinician, the clinician must be good?
- Look up your medical problems online, and try to determine for yourself whether you’d been getting the right medical care?
- Get a second opinion from another doctor?
My guess is that most patients and families end up trying one – or both – of the last options. In this post, I’ll explain why I’ve come to believe that facilitating second opinions is integral to empowering patients, and to improving the quality of outpatient care.
Why seek a second opinion
I don’t know about you, but when I’ve found myself trying to solve a problem in which I lacked adequate expertise, I’ve turned to a professional for help. (I haven’t had to do this for medical reasons in the past decade, but have done it for issues such as home renovation and website design.)
And in many cases, after meeting with an expert for a while, I’ve then turned to yet another expert to get an additional perspective on the issue at hand.
Continue reading “How Patients Can Assess the Quality of Their Outpatient Care”
Filed Under: THCB
Tagged: Geriatrics, Leslie Kernisan, Patients, primary care, second opinions
Jun 27, 2013