It’s been two years since I first started my new practice. I have successfully avoided driving my business into the ground because I am a dumb-ass doctor. Don’t get me wrong: I am not a dumb-ass when it comes to being a doctor. I am pretty comfortable on that, but the future will hold many opportunities to change that verdict. No, I am talking about being a dumb-ass running the businessbecause I am a doctor.
We doctors are generally really bad at running businesses, and I am no exception. In my previous practice, I successfully delegated any authority I had as the senior partner so that I didn’t know what was going on in most of the practice.
The culmination of this was when I was greeted by a “Dear Rob” letter from my partners who wanted a divorce from me. It wasn’t a total shock that this happened, but it wasn’t fun. My mistake in this was to back off and try to “just be a doctor while others ran the business.” It’s my business, and I should have known what was happening. I didn’t, and it is now no longer my business.
This new business was built on the premise that I am a dumb-ass doctor when it comes to business. I consciously avoided making things too complicated. I wanted no copays for visits (and hence no need to collect money each visit). I wanted no long-term contracts (and hence no need to refund money if I or the patient was hit by a meteor or attacked by a yeti). The goal was to keep things as easy as possible, and this is a very good business policy.
A rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.
Treating the Well:
In my early career in Sweden, well child visits were done in nurse-led clinics, some of them only open on certain days, with a local doctor in attendance. Parents carried the children’s records with them, containing growth charts, immunization records and so on.
These nurses had great expertise in differentiating normal from abnormal appearance of children, and would direct the attending physician’s attention to children with abnormal metrics, appearance or behavior.
With this arrangement, the physician time requirement was reduced, and limited to evaluating children attending the clinics who needed special attention. Physicians also performed specific examinations at certain ages, such as checking for hip clicks. These clinics freed up the local pediatricians to evaluate more sick children.
Well-baby visits are now the bread and butter of American pediatricians and family practitioners, and with the ever expanding mandates of politically determined items that must be covered in order for doctors to get paid for their services, we sometimes have trouble accommodating illness care demands.
My life changed dramatically 18 months ago when I started my new practice. The biggest change personally was a dramatic drop in my income as I built a new business using a model that is fairly new. That’s a tough thing to do with four kids, three of whom were in college last fall. OK, that’s a stupid thing to do, but my stupidity has already been well-established.
Yet even if the income stayed identical to what I earned before the switch, the change in my professional life would have been nearly as dramatic.
I am no longer focused only on patients in my office.
I am no longer focused on ICD and CPT codes.
Saving patients money has become one of my top priorities.
I feel like my patients trust me more, and see me as an ally.
Patients accept my recommendations for less care (avoiding unnecessary testing and unnecessary medications) much easier.
I focus far more on preventing problems or keeping them small.
I laugh with my patients far more.
I no longer feel like a Zombie at the end of the day (and I no longer eat brains)
Times have changed. And it’s time they change again.
In the past, medical care was more episodic than it is now. People went to see the doctor when they felt unwell. Diabetes affected mostly older patients, who didn’t live long enough with the disease to develop complications.
There were no blockbuster drugs for high cholesterol, Hepatitis C, fibromyalgia or chronic heartburn; we didn’t manage nearly as many patients on multiple medications as we do now.
In those times, a payment scale based on the length and complexity of the visit made sense, and there wasn’t much doctor-patient interaction between visits.
Today, we manage more chronic conditions, use more medications, do more laboratory monitoring, more patient education, and more administrative work on behalf of our patients than before.
Payment scales based only on what we do in the face-to-face visit have become hopelessly antiquated and stand in the way of the new demands of society – physicians providing longitudinal care for chronic conditions in patient-centered medical homes.
The janitor approached my office manager with a very worried expression. “Uh, Brenda…” he said, hesitantly.
“Yes?” she replied, wondering what janitorial emergency was looming in her near future.
“Uh…well…I was cleaning Dr. Lamberts’ office yesterday and I noticed on his computer….” He cleared his throat nervously, “Uh…his computer had something on it.”
“Something on his computer? You mean on top of the computer, or on the screen?” she asked, growing more curious.
“On the screen. It said something about an ‘illegal operation.’ I was worried that he had done something illegal and thought you should know,” he finished rapidly, seeming grateful that this huge weight lifted.
Relieved, Brenda laughed out loud, reassuring him that this “illegal operation” was not the kind of thing that would warrant police intervention.
Unfortunately for me, these “illegal operation” errors weren’t without consequence. It turned out that our system had something wrong at its core, eventually causing our entire computer network to crash, giving us no access to patient records for several days.
The reality of computer errors is that the deeper the error is — the closer it is to the core of the operating system — the wider the consequences when it causes trouble. That’s when the “blue screen of death” or (on a mac) the “beach ball of death” show up on our screens. That’s when the “illegal operation” progresses to a “fatal error.”
The Fatal Error in Health Care
Yeah, this makes me nervous too.
We have such an error in our health care system. It’s absolutely central to nearly all care that is given, at the very heart of the operating system. It’s a problem that increased access to care won’t fix, that repealing the SGR, or forestalling ICD-10 won’t help.
It’s a problem with something that is starts at the very beginning of health care itself.
I have felt from the start that this practice model is far better than the one I had in my former life, including:
Better experience for the doctor
Better experience for the patient
Better care quality
Savings for the patient and for the system.
The last one on the list is the hardest to prove, and I am potentially getting someone to gather concrete numbers for patients who followed me from my old practice to see if their overall health expenditures are down from before I started this practice. This will take time, however, and I am not sure the sample size is large enough to account for the normal variations (either in my favor or against).
Yet some anecdotes from the recent past suggest the answer, giving evidence of significant savings, both financial and life quality, that my patients and their payors get. This is an important case to be made to both the patients (who want to know if their $30-60/month is worth it) and payors (who could financially benefit from promoting this practice model). I realize that this does not constitute a proof of concept, but it is not without meaning.
PATIENT 1. MEDICARE. AGE: 90+
Pt had a head injury and came to my office wondering if they should go to the ER. I assessed the mental status did an exam, determining that this was not necessary. Set up imaging study that day (CT without contrast) which came back negative.
In my old office, the nurse who answered the message would have immediately suggested going to the ER, not checking with me on this.
Cost: CT without contrast as outpatient – cash price $300, not sure about negotiated price.
Savings: Avoided ER with head injury work-up. Cost: ? (More than $300 by far).
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.
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.
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…
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.