The Good Doctor Calls For Backup

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.

Sorry, Bill.

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:

  1. I hate to sound whiney.
  2. I don’t want people to worry that things are worse than they are.  Especially my patients.
  3. 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.

It was as if I was in the TJ Max dressing room, desperately trying on clothes for a formal dinner with the president.  I was looking in the wrong place for what I needed, yet I couldn’t go naked.  So do I keep looking, hoping that something would work, fracturing the already disjointed patient records all the more?  I knew what I needed to truly give good care for my patients, yet nobody came close enough for me to be willing to overlook the deficiencies.  The alternative I was now facing was one I desperately resisted: to build my own system.  I resisted this idea because:

  1. I am a doctor, not a computer programmer.
  2. Medical records are incredibly complicated.
  3. My time was limited.  I couldn’t spend all of my time on something that didn’t itself generate revenue.

But in April, two moths into my practice, I dove head-first into the icy water of the enormous task of building my own record system.  Since that time I have spent (even by my own work-a-holic standards) an incredible amount of time working on the project.  Whereas in the past I’ve been motivated by the obsessive fun of building something, this was driven by the ever-growing fear of drowning financially.  If I couldn’t build a system on which my practice could not only work, but thrive, I would eventually be drawn down to the icy depths.

This is why my writing has dropped off over the past few months.  Every day my creative energy is sucked dry, leaving me in the evenings only enough energy to play “bejeweled” or watch “Alias” on Amazon.

Adding to the stress of creating a new record was the state of my previous medical records.  They were all over the place, stored in the 5 different systems I tried while coming to the realization that my search was futile.  Not only did I need to put these records into my new system, I had to scrounge around for them when trying to give care for my patients. Over the most recent months, my focus has been on improving the quality of care I give, rather than to grow my overall patient volume.

This, unfortunately, doesn’t do well for my bottom-line.  It’s hard to convince my mortgage company, the colleges three of my kids are attending this fall, and the grocery store, that money is tight and that I deserve a break.  Just as the water doesn’t treat a non-swimmer with gentleness, the reality of finances are pulling me ever downward.

This puts me at a huge decision point: I don’t think I can grow the business enough with just me and Jamie doing the work, yet adding people would cost money I don’t have and delay my own salary even more.  Yet I need someone to take away the business tasks I’ve done out of necessity (but am not good at).  Plus, we need to be working on setting up contracts with small businesses, developing the side of the business I think has the most potential.  Plus, it would be real nice to have someone else be responsible to make decisions.  I find myself even resenting having to decide what to wear, or what to have for dinner.

So I am working on getting the finances necessary to do hire a business manager (and already have someone in mind).  I feel like my efforts to build a record system that will support my business model are paying off.  There are just a few areas left to build, and I’ve had a delightful amount of help in working on their future development. So now we need to start capitalizing on the huge amount of grease I’ve exuded from my elbows over the past six months.

The driving force behind all of this – the thing that keeps me from giving up – is my belief in what I am doing.  I believe in this practice model.  I really feel it is a game-changer.  If it works like I think it can, it will improve the quality of care, reduce it’s cost, and make the experience much better for both doctors and patients.  If it can work on a bigger scale (more than 1000 patients per PCP), then it is goes from good idea to a very compelling alternative to doctors, patients, employers, and insurance companies.  It could be huge.

As of now, however, I am still in the water struggling against gravity.  This is the hard time.  It’s not easy.

Maybe I should call Steven V and see if he can tell me how it’s done.

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 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.

8 replies »

  1. I’m really inspired together with your writing skills as well as with the layout to your blog. Is this a paid theme or did you customize it your self? Anyway stay up the excellent quality writing, it is rare to look a great weblog like this one these days..

  2. Rob,

    While I can’t offer any solutions to your EMR dilemma (I suspect you are better at technology than I am) I did want to ask you how do you call to yourself the attention of small businesses? I’m having a terrible time trying to let small businesses know I exist and that I’m a local direct primary care alternative. Any thoughts? Thanks.

  3. Well, the focus is right . . . .

    “system oriented toward work flow optimization, communication, and care rather than the current EMR systems which focus on documentation and compliance.”

    but you could probably just as easily take on building the next generation Ferrari in your garage, if you want to end up with a commercial product.

    Bottom line, there are solutions out there that have their foundation in ACM (Adaptive Case Management) / BPM (Business Case Management) but these were not invented on the back of an envelope (1,500,000 lines of computer code). Not all have a singular focus on documentation and compliance.

    I have a blog with more than 150 posts on workflow management topics (healthcare, manufacturing, b2b) and curiously the most recent post you will see if you go to http://www.kwkeirstead.wordpress.com is “Thinking of building a healthcare e-Hub?”.

    IT is feasible/practical to build an EMR for a solo practice – what you put in it is up to you. Putting a commercial enterprise product on the market is another thing altogether.

    Most of the customers of the products that Civerex has developed end up using 5-10 percent of availability functionality, but when you look across the customer base, different customers use different features/functions.

    I suspect for office products like MS Word and MS Excel the situation is much the same.

  4. Rob: Thanks for sharing these unvarnished truths. I am awed by your effort and motivation. I’m also struck by how your story illustrates just how much work doctors can expend on figuring out the infrastructure of a practice. How hard can it be? Super hard, which is part of why docs are loath to change what they are doing.

    I do hope you’ll eventually write more about direct primary care and how it can be scaled up. Am also looking forward to eventually learning more about the EMR you’ve designed…I would love to find something that helped me keep track of 15 active problems, and allowed me to collaborate with families on a joint action plan.

  5. This post combined with the one about the Residents from Oregon coming up with their own system tells a sad tale about EMRs.

    Of course, nobody in DC is listening and quite a few readers of THCB aren’t either.

  6. I can’t speak for the rest of THCB readers but I’d like to see more detail on your thinking about a). How EMR workflow can be redesigned. b). What you found lacking about the products you tried? Can you talk about the five EMRS that you tested and offer a brief critique of each? c). Your own design philosophy ..

  7. Nick: Right now my goal is only a prototype to show a system oriented toward work flow optimization, communication, and care rather than the current EMR systems which focus on documentation and compliance. I don’t, therefore at all intend to become “certified” in anything (although some folks already think I am certified to be doing this in the first place). It’s really hard to explain what I am doing, but plan on opening things up in my writing soon. My goal is to show some folks better at tech I am just what a patient-centered record would look like. They can then take it out of the prototype stage and make something more functional out of it.

  8. Best of luck on this venture! I enjoy reading your posts on THCB.

    What sort of stack are you using to write your EMR system? We are writing our own EMR for Oncology (Ankhos) and it would be great to exchange stories/problems/successes.

    Are you aiming for meaningful use or CCHIT certification?

    We are using Python and Django to make a thin-client web app.