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Three Wishes

So I was walking down the hallway in my office, mildly distracted,
when I kicked something.  It was a USB “thumb drive.”  I picked it up
and inspected it, trying to figure out who had dropped it.  The side of
the drive had a picture that I couldn’t make out, as it was all smudged
with something.  I pulled out a tissue and rubbed it, thinking it may be
a clue as to whose drive it was.

There was a sudden rushing sound and a strong wind.  Out of the thumb drive emerged a large blue figure wearing a turban.

“Are you a genie?”  I asked

“No, I am David Blumenthal, the health IT ‘czar.’” he responded.

I hung my head down, “I guess this is about the fact that I write the word healthcare instead of health care. I was wondering how long it would be before the feds came down on me for that.

“No, that’s not my realm.  That would be the job of the Department of
Language Security, and they’ll be appearing in some creative way next
week to get on your case about the whole healthcare thing.  It has Matthew Holt and Maggie Mahar in a big tiff.”

“So why are you here?” I asked, “And why are you doing that whole genie gig?”

“Ah, well president Obama saw that you weren’t using email to
communicate with your patients, and he sent me to find out if there was
any…ah…persuasion we could do to get you using it.”

“I do use email to communicate with my patients!” I said. “I
just don’t do any e-visits, substituting an email dialog for an office
visit.  Are you able to fix this problem?”

He got a small smile on his face.  ”That is why Obama sent me in this
genie get-up.  He said that I could grant you three wishes on the area
of electronic communication with patients.  That’s what I am here to
grant.”

“And where did you get the ability to transform like this?”

“Saddam Hussein had a bunch of lamps stored away in his bunkers.  It
turns out that instead of weapons of mass destruction, he was hoarding
weapons of wish production (known as WWP’s, to us government types).”

“Who’d have thought….anyway, I have three wishes to get to, right?”

“Right.  But don’t wish for more wishes, and definitely nothing to do with llamas.”

“Got it.  Well, you know that I am a big computer geek and an early adopter of technology?”  I asked.

“Your geekiness is known nationally.”

“Great.  Well, the idea of e-communication is not only something I am
not against, it is something that I would love to adopt.  The problem
is in the payment system, not in the reality of doing it.  I think I
could do it without much problem; I just don’t want to start giving
things I have made my living on away for free.”

He looked bored and annoyed.  ”I know, I know.  I am as impatient as
you about that.  The problem is that our lovely congress is in charge of
fixing the payment system.  That’s like asking a toddler to fix a
broken vase.  Still, I am a genie now, so maybe we could work something out.  So what are your wishes?”

“My first wish is that e-communication would replace phone communication whenever possible.
Patients don’t like to listen to our Muzak or figure out our
voice-mail system, and would much rather send an email than leave a
message.”

“I know.  You can only listen to Kenny G for so long.”

“It does bring in business for acute nausea, though.”

“I hadn’t thought of that.  So why don’t you just put a communication
link on your website so they can request refills, appointments, and ask
questions?” he asked.

“We already do the first two, and the patients are pretty happy with
the convenience.  But the last one is the real problem.  If we get into
an email conversation with the patient, it is recorded for all
posterity.  We are legally liable for anything we write to them and for
anything we receive.  With that kind of liability, plus the risk of
losing income, we just can’t afford to do it.”

He thought for a moment and said, “So you want me to reform the legal system to reduce your liability?”

“That would be a big start.  We’re humans, and prone to mistakes.  We
can’t be looking over our shoulders for the 1-800-SUE-DOCS” lawyers
looking to get their windfall.  We need some protection in the
day-to-day management of patients.  The use of electronic communication
greatly increases documentation, and increased documentation greatly
increases potential liability.”

“OK, I’ll get to work on that one.  What’s your next wish?”

“My second wish is that e-visits would replace frivolous office visits.
I don’t like to see people for every little cough they have, but many
employers require personal office visits for doctor’s excuses.  The
schools are even worse at this, ever since the crazy No Child Left Behind legislation was passed.”

“I had an itch on my left behind once.”

“Too much info.”

“Sorry.”

“Anyway, we need to be able to get paid for simple visits that could
be handled via email.  We need to be able to get paid for the management
of their care as well as the risk we take giving care.  The same holds
true for people with chronic disease.  If we could check on people
regularly via email, or even by phone, to make sure they were doing OK,
then maybe they’d have to come in less and get sick less.”

“The latter sounds like the patient-centered medical home.  People are working on that one.”

“Correction: congress is working on that one.”

“I stand corrected.  So what you want is some sort of payment system
that allows dumb visits to be handled electronically.  I think that’s in
my power as a genie. I’ll have to ask my boss first.  So what’s your
last wish?”

I stood there for a few minutes, scratching my beard and thinking.
”You know, if the legal side of things got reformed as well as some
sort of payment for e-visits, other things would fall into place.
Patients could handle more without coming to the office, so there would
be more availability of docs.  Plus, they wouldn’t resist coming in as
much if they knew we were willing to handle things online.  I can’t
really think of a third wish.  Can I have a rain-check?”

“That’s another thing I’ll ask my boss.  Just don’t take too long, and remember the llama stipulation.”

“That’s a shame, you know.  Having llamas replace those folks in the
senate may get things working better than with the folks we have in
there now.”

“Llamas in congress?” he asked, eyes widening. “Hmmm…I hadn’t thought
of that.  I am sure that the prez wouldn’t mind that one.  I’ll get
back to you on that one.”

“That’s alright.  I’m when I hear the passage of pro-poncho legislation I’ll know you’ve done your magic.  Thanks!”

“No problem.  Now, can you click the little switch on the side of that drive so I can go back in?”

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where 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.

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33 replies »

  1. have them tap the phone or mouse on the efflicted area and listen for the cause of the ailment

  2. Just how do you perform a physical exam on a patient over the phone or the net?

  3. Nate: Yes, I agree. The idea (for those still not understanding it) is that with HSA accounts, you can deduct non-prescription meds. The goal overall is to make the encounter as efficient as possible, be it online or in person.

  4. inchoate, correct you just can’t pay with pre-tax dollars. Rob and Margailit I wasn’t suggesting dispensing anything in office but those OTC items that now require a prescription. Margalit I wouldn’t expect someone to pay for an office visit either to get nyquil, I also wouldn’t expect a doctor to charge a full office visit to prescribe it. The family doctor isn’t always that much further away then the drug store. If you could buy it from the doc pre tax vs paying post tax at the drug store i would think that would interest some people.
    You can make a lot of money treaitng the needs of only some people, not everything has to be an all emcompassing solution.
    If this medical home idea ever takes off wouldn’t picking up such treatments at your doctors office make since.
    If a Doc could make $10 for trading some emails with a patient then prescribing nyquil doesn’t that have some value to both? Doc knows the patient was sick, has a record of it and the patient has kept their Doc informed and save 20%.

  5. tim wrote:

    For society to push the caregivers to document more and better, while turning the gaze away from what that documentation represents to the lawyers, and then be amazed that the medical community is not just gaga over the helping hands…is not likely to succeed.

    so, let’s see. You want me to feel sorry for doctors who have more incentive now to document their work in a way that could have much more value to me, and to them, and to everyone, than their sheafs of manila folders now do – on the offchance that they may be leaving a trail that rapacious lawyers might be able to employ to plunder the physician’s malpractice insurer?
    ok. I’ll schedule 15 minutes for that, 4 weeks from now. That works for me (I really don’t care if it works for you).
    Sound familiar?

  6. Nate wrote:

    “To answer your question, I think $20 per e-visit would be fair.”
    $20 sounds fair as well, so why don’t you start offering it? Insurance won’t pay for it but insurance shouldn’t be paying for $20 routine services anyways….

    When you put your mind, rather than your anomalous political fancies, into it, you can write some compelling stuff. The whole of that post is a gem.
    However, I believe this item

    Effective 1/1/2011 individuals can’t pay for OTC items without a prescription.

    needs clarification. Obviously people can continue to buy over-the-counter products without a prescription after 1/1/11, they just can’t pay for them with tax-favored dough from their health savings account without a doctor’s Rx.

  7. The other downside of in-office dispensing is self-referral. You are more likely to use something you make money off of. I’ve written about this – this is why we don’t do our own x-rays any more. I don’t want to be motivated financially to prescribe more or order more tests. That’s always an area to tread lightly on, but it is a dilemma we face daily. Why did the pediatrician check a urine and a hemoglobin every time I visited as a child? Because he could, and he got paid for it. Why not? Except for the small fact that it is unnecessary and can lead to more unnecessary tests.
    I have heard that to offer a service to non-medicare and non-medicaid patients without also offering it to them has some legal problems as well. I am not sure about the overall legality of offering better service to people with a certain insurance contract. A friend who innovated in this way ended up dropping both Medicare and Medicaid so he could use email on a subscription basis.

  8. Nate, in office dispensing has lousy margins unless you are in workers’ comp and with the advent of $4 Walmart drugs, it’s pretty useless. Dispensing OTC would probably be even less lucrative, and I don’t know anybody willing to pay for an office visit (even at a Minute Clinic) just so they can deduct 3 dollars worth of generic cough syrup.

  9. Medicare and Medicaid I understand, they aren’t the ones you want to try to innovate with. As to the remaining 70% of your business my parents and I owned a PPO for 15 years or so, having written and signed more thousands of contracts then I care to rememember I am quite familiar with how they read and what they allow you to do and not do. As a payor that works with 40+ PPOs I think I have a pretty good idea of what’s out there.
    I have never seen nor heard of a PPO contract that would prohibit you from offering your services to your patients in any legal manner you so desire. While those contracts might exclude reimbursement from the insurer that just goes back to the argument they shouldn’t be paying anyways. Trust me if I could write a PPO contract that precluded treatments I don’t like from even being offered I would have been all over that 10 years ago, sleep studies, early biratric surgery, etc etc.
    If your billing the patient direct then it matters even less what your PPO conract says.
    This conversation brings up another opportunity I haven’t seen any doctors address but which should be. Effective 1/1/2011 individuals can’t pay for OTC items without a prescription. I have yet to see anyone offer an affordable solution to this. I dont recall the exact numbers but congress expected to raise 11 billion with this change. That 11 billion is comming out of consumers pocket, I would think they would be more then happy to pay a couple hundred million to a billion to get the Rx and keep the savings. Lot of money sitting there for doctors not to be doing something.
    Are their any laws that prevent a doctors office from selling asprin, nyquil, and other commone OTC treatments? This could be a great selling point for Take Care and Minute Clinics, come see us and we’ll write a script for your FSA.

  10. I sign a contract with each insurance company I accept saying their fees are acceptable. It is not so simple to bypass them, as they are legally-binding contracts. I accept both Medicare and Medicaid as well (with about 15% of my practice being each of them), and the legality of charging for a service beyond their rates is also a stumbling point. I think you underestimate the complexity of this.

  11. sorry keep thinking of more things after I hit post.
    HSAs and FSAs and even HRAs are now over double digit penetration. Consumerism of healthcare is happening and happening quickly. People are looking for alternatives like this but they aren’t being offered. We have members ask all the time how they can save money or get something cheaper. I would suggest the first people you target are those with an HSA. They will grasp the benefit and be more willing to try it. Once they try it and are happy then they will tell others not on an HSA.

  12. ” If I had a cash-paying population, the I would most certainly be doing it.”
    If you never give your patients the opportunity to be cash paying customers how can they be?

  13. “To answer your question, I think $20 per e-visit would be fair.”
    $20 sounds fair as well, so why don’t you start offering it? Insurance won’t pay for it but insurance shouldn’t be paying for $20 routine services anyways. If I was a patient of yours and had a choice of taking half a day of work and spending 2+ hours in your office so I could pay a $20-$40 co-pay or paying you $20 and getting the same result I would be all over that.
    Unless your patient base is all Medicaid I don’t see how they couldn’t afford this. Aren’t they already paying this much for regular office visits today?
    “but once it steps into the realm of giving away what we normally charge for (patient problems driving specific medical decision-making and advice), then we are simply letting the insurance companies off of the hook for something they should pay for.”
    Talk like this always scares/angers me. I didn’t sell you a policy and you have never paid me a penny of premium, why do you feel I am obligated to pay you anything? Insurance, when it functions properly, is the exchange of risk for premium, where is the risk in needing an office visit. This is something that shouldn’t be insured at all in the first place or only insured if the person requires more exams then a normal person during the course of a year. You provide a service to your patient; I also provide a service to your patient. You’re not letting me off the hook or putting me on it when you charge or don’t charge. Your transaction is with your patient. In a separate transaction your patient and I will decide if he wants to insure a risk and if so how we will reimburse it.
    Why is it you feel you can’t conduct business with your patients outside of any interdependent relationship with an insurer? People easily paid 50% of their personal healthcare expenses out of pocket before government started fixing healthcare. There is no law, either human nor economic, that says you can only sell services reimbursed by insurance. It seems the only thing preventing this are your own preconceived notions. Besides a few hours thinking it through and training your billing staff what do you have to lose? If you offer it and no one buys you have lost a couple hours. If it works half as well as one would expect you could have a significant new revenue channel and much happier patients.

  14. Funny, I see much PICONIC (problem in computer, not in chair). The vendors and hospitals have been trained by the consultants to always blame the user. The poor usability of many of these systems generate errors, and of course, they are blamed on the users.
    Rob, it is refreshing to read of your honest appraisal of the situation with HIT.
    If there was more scrutiny and surveillance of the HIT, ie a place to lodge formal complaints, the systems will improve quickly.

  15. Connie: HIT will ALWAYS be difficult, because medical documentation is beyond complex. We have been profitable with our EMR system for over 15 years, and have higher quality numbers than most other PCP’s (all other PCP’s not on an EMR, I would dare say). Yes, we work around the defects, just like we work around the side-effects of necessary drugs. There are downsides, but they are outweighed by the upside, in my opinion. Too many docs expect an EMR they can walk into without having to work to make it function well in their system. EMR vendors are simply taking advantage of this wish and giving docs vapor ware or false promises. Having spoken the IT message to docs for well over a decade, I can confidently say that it is a PICNIC situation (Problem In Chair Not In Computer). I am far more frustrated with docs than with IT vendors.

  16. Blumenthal is the genie for the White House and Sec. Sebelius, promoting dreamy illusions of the benefits of HIT while bankrupting small, but good hospitals, desperately trying to jump through his hoops and those of Congress.

  17. Jack: Many have pondered the whole llama thing, but none (including myself) have figured out what it’s all about. It matters not; it IS.
    I thought you were just being British with the “an.”

  18. Nate: I already know what will and won’t be paid. It’s not like we put charges out there and wonder if insurance will pay. There is no “testing of the water.” We have fee-schedules for any insurance company we accept, and so can just run the numbers. It’s not at all like Wal-Mart, because Wal-Mart has a cash-paying population. If I had a cash-paying population, the I would most certainly be doing it. Look at the concierge practices out there; nearly all of them employ the use of email, etc.
    To answer your question, I think $20 per e-visit would be fair. If a person ended-up with the doctor recommending they come in to be seen, then the $20 would be applied to the visit. I think that’s fair. Think about all of the parents who come and see us just to get a school excuse. They know their kid has a virus, but the school system counts any absence without a doctor’s note as an “unexcused absence.” That’s a wast of both ours and the parents’ time.
    Dennis: See above comment about cash-paying customers. Cory Doctorow can set whatever charge he wants for things, and chooses to not charge. For him the business model is set by Cory Doctorow. For us, the model is set by the insurance companies. I certainly do as much e-communication as possible with patients (although HIPAA would crush anyone who used Twitter or Facebook), but once it steps into the realm of giving away what we normally charge for (patient problems driving specific medical decision-making and advice), then we are simply letting the insurance companies off of the hook for something they should pay for. This is a Win-Win-Lose proposition, with the biggest win being on the side of the insurer who can cut cost and increase satisfaction on the back of the biggest loser: the PCP. The patient wins too, except that the increased burden of the PCP may make the attractiveness (already tarnished) of med students choosing primary care even less.

  19. Sorry, my typing isn’t the best. I meant to say that you have “a” very strange obsession with llamas!

  20. Connie, let’s face it, if Don Berwick farts, the insurance companies will use it as an excuse to increase malpractice insurance.
    As for Doc Rob’s claim

    Well, the idea of e-communication is not only something I am not against, it is something that I would love to adopt. The problem is in the payment system, not in the reality of doing it. I think I could do it without much problem; I just don’t want to start giving things I have made my living on away for free.

    Doc, have you ever heard of Cory Doctorow? He puts whole novels online, and he seems to be doing fine. Knowledge is undiminished by the sharing.
    Now, I’ll grant you that family practitioners have been generally screwed by the fee-for-service system, but not counting the specialists, we’ve all been screwed by the FFS system. Don’t punish your patients because of it.
    If you try it, Doc, I think you’ll find like the PCMH folks that a considered use of email will actually work out in your favor. Health tips, exercise recommendations, info on supplements, vaccinations, even diet data, can be handled in email, Facebook, or Twitter. You can use email to answer simple questions instead of tying up a patient for an entire half-day’s work (you know, the hour in the waiting room, the fifteen minutes freezing in the exam room, the fifteen minutes to and from the office) and ripping them off for yet another $30 copay (which they are, after all, paying to you in addition to the payments they make to the blood-suc–uh, insurance companies). Then, once your patients start demonstrating healthier habits than others in your area–spending less time in the hospital and taking off less time for sick leave–you can use that as a bargaining chip in dealing with the insura–vampires.

  21. Rob, The smudged picture on the side of that USB drive was probably Kaiser Permanente’s logo… and had you checked its contents, my guess is that you’d find it contained a boatload of unencrypted PHI since Kaiser Permanente never bothered to put the appropriate safeguards in place to protect the “health” (not healthcare) information of its members.

  22. Rob,
    How much do you want paid for an e-consult? I don’t really buy the whole I don’t get paid argument if you haven’t offered it yet. I equate that to Wal Mart saying they won’t sell asprin any longer cause employers won’t pay them.
    I don’t think manu patients are fans of packing up the kids, driving across town in mid day traffic, sitting in waiting rooms, I could be wrong maybe you keep an especially fresh supply of reading material and offer a few TVs with variable viewing options, but the point is there is value to the individual to not have the exam either.
    Seeing as how $30-$40 office visit co-pays are common, depending on how much you want to charge, insurance might not pay for it anyways. If you could resolve the legal fears there is nothing to stop you from getting paid directly by the member without involving insurance at all. If you some day do want insurance to cover it you are much more likly to achieve that if thousdands of members are asking for it and you can demostrate success. I have all sorts of questions about utilization, fraud, excess correspondence, need, etc I would want answered before I started covering them, those questions will never be answered if you wait for me to cover it before you offer it.

  23. Malpractice carriers have already reported on the increased legal hazzards of EMRs. As an HIT expert for the plintiffs, I enjoy the detective work to discover how the user unfriendly HIT computerization has been a primary factor in deaths and permanent injuries. You are all seduced by dreams that these devices are going to protect you. It will only get worse with more scrutiny, RAC audits, and malpractice. Each case I review has a few more reams of paper that has been regurgitated by the device.
    At a few hundred $ per hour, I am doing quite well thank you. Making more than taking care of Medicare patients, and much more fun.
    Take solace in that I try to limit the accusations against the doctors and direct them at the HIT vendors.
    Hospitals tend to blame the users as do the vendors, but I know you guys are trying hard to work around the defects of the software.

  24. “Dr. Rob, from your post I get the impression your lawyer has persuaded you that you can make practically any blunder you like during a phone conversation, but woe betide you if you misplace a comma in an email exchange.”
    This would be the trial lawyers’ view.
    Actual mistakes are not what he is talking about. The ability of lawyers to successfully depict a comma as a mistake — to a goofy jury — that’s what he is talking about.
    The medical profession doesn’t believe the legal profession sees the patient record as anything other than raw material for extortion. The physician’s record of a phone conversation puts him only in a position of explaining his own thoughts and words to the jury; the same conversation via e-mail gives the villains at least twice as much material to twist.
    Surprising, I know, that he is not getting legal counsel about patient care, but about litigation tactics. He is not interested in parsing the relative harm done to patients by the medium of an error; he is interested in the relative value of media to a plaintiff. To voluntarily give them more opportunity to steal your childrens’ college fund would be plain stupid.
    Whether you agree or disagree with this polarized view is not important; it is the dominant (and growing) view of the physician community.
    For society to push the caregivers to document more and better, while turning the gaze away from what that documentation represents to the lawyers, and then be amazed that the medical community is not just gaga over the helping hands…is not likely to succeed.

  25. I also question the increase malpractice with EMR. Some malpractice vendors do offer discounts (although the benefit is not nearly as good as was originally touted). That’s not my point at all. My point is that having patient input directly into the record increases liabilty in certain ways. We need to have laws catch up with the technology.

  26. “Malpractice Insurance rates are increasing due to EMRs.”
    “Please cite a source for this statement.”
    ___
    I’d like to see that as well. I’ve been to presentations put on by medical liability insurors wherein they tout the adoption of EHRs and offer discounts for providers doing so.

  27. “Malpractice Insurance rates are increasing due to EMRs.”
    Please cite a source for this statement.

  28. Malpractice Insurance rates are increasing due to EMRs. They create more errors and more complex forensics.
    The hospitals are also hiding information. Either they do not know how to operate their own electronic record system or they are covering up the errors.

  29. inchoate: You, of course, are correct…in theory. The reality is that more documentation does equal more liability. Even if it doesn’t, it equals more FEAR of liabiltiy, which is enough to make most clinicians run and hide from it. This is exactly why I have not started taking pictures of rashes and lesions on my patients and including them in the chart. If I describe what I see, I am not describing what I am missing. Yet on a photo, there is for all to see things I have missed (If I have done so).
    This is the dillemma of medical records. We are liable as much for what we record (or don’t record) than we are for what we do. I wish the decision were wholely based on what was best or the patient, but there is a point at which a risk is too big to take. Feel free to disagree, but all lawyers know that there is “discoverable” evidence, and there is hearsay. My word against the patients is not discoverable if it is based on recollection of a conversation, while my written word is not a thing for (much) debate. Perhaps you don’t live under such pressure, but it affects me and other physicians every single day. If it is not real, then the perception is so ubiquitous that it might just as well be real.
    I am sorry your head hurts, but I don’t dare tell you how to make it feel better.
    Just kidding.

  30. Dr. Rob wrote:

    But the last one is the real problem.  If we get into an email conversation with the patient, it is recorded for all posterity.  We are legally liable for anything we write to them and for anything we receive.  With that kind of liability, plus the risk of losing income, we just can’t afford to do it.

    Dr. Rob, from your post I get the impression your lawyer has persuaded you that you can make practically any blunder you like during a phone conversation, but woe betide you if you misplace a comma in an email exchange.
    Else why the distinction? “Phones are ok, because you can get away with boners – there’s no record of what you said, see? – but email? There it is in black & white, after all.”
    My head hurts just imagining what else that nitwit must have ‘informed’ you about. I begin to imagine that you have really not given a second’s thought to which mode of communication is appropriate for what sort of situation – but I’ve read several of your posts, and they’re lucid, even funny at times (not always where you think they’re funny, but that’s true with everyone, right?)
    So, allow me to supply you with your 3rd wish: for more capable legal counsel.

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