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

“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

“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.”


“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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Craig Vickstrom, M.D.Margalit Gur-AriejustineJackDennis (Investigator/Negotiator) at Medical BillDog Recent comment authors
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Craig Vickstrom, M.D.
Craig Vickstrom, M.D.



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

Craig Vickstrom, M.D.
Craig Vickstrom, M.D.

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


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.


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… Read more »

inchoate but earnest
inchoate but earnest

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… Read more »

inchoate but earnest
inchoate but earnest

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… Read more »


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… Read more »

Margalit Gur-Arie

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.


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… Read more »


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.


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.


” 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?


“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… Read more »


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.