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.
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.
Yeah, I am recovering…doing a lot better, actually. Things are tough, but they are a lot better since I left my destructive relationship with Medicare, Medicaid, and insurance companies. I’ve had to learn how to manage my own money (now that I can’t count on them to bail me out any more), but things are looking a lot better. I am beginning to see how much better it will be to be on my own.
The key was when I realized that the system wasn’t going to change no matter how much I accommodated its unreasonable requests. I felt that if I only did what it asked of me, however unreasonable, it would stop hurting me and, more importantly, my patients. But I’ve come to see that all the promises to take care of me and my patients were written in sand, and that it couldn’t resist the temptation to cheat on me. I tried to do what it asked of me, but as time went by I couldn’t take how dirty it made me feel.
I want to believe it was sincere when it told me it wanted to change. I think at its core, it wants to help patients and doesn’t want to go on those spending binges. But no matter how sincere the promises sounded, I was always left alone as it threw its money at every sexy treatment, procedure, or drug that walked by. Then it would go off on tirades about how much I spent and that I didn’t do enough to keep to our budget. It was always my fault. I think it’s just easier to pass blame on others than it is to do the hard things necessary to really change. To be honest, I think it was terrified at how much real change would hurt.
But I can’t sit around and wait for the system to change any more. My patients were getting less and less of my time, and I was getting to the breaking point. I know there are a lot of other doctors who are willing to do whatever the system asks, but I can’t sit around and watch it self-destruct. It’s not what’s best for the system, for us doctors, and for our patients. Sometimes the best thing you can do for someone is to let them self-destruct and pray that they finally take responsibility and learn the hard lessons. I just hope that happens soon.
A post I wrote nearly three years ago has recently gone viral, bringing tens of thousands of readers and a huge number of comments. It’s a letter I wrote to my patients who do something that all but guarantees a bad relationship with many (if not most) physicians: they don’t get better. There are basically two responses I get to this post: either readers are grateful to have a doctor admit to our flawed humanity, or they are furious that I would suggest that patients, the ones with the disease, should see physicians as needy and flawed humans and therefore watch how they act around them. If you haven’t done so, read the comments to this post and hear the deep frustration and anger brought out by a letter that sympathizes with their pain and (apologetically) tries to help.
Amidst the dichotomy of reactions, both of which I understand, is the obvious question: why has a relationship that exists for the purpose of healing and helping become one of frustration and anger? The corollary to this question is perhaps more important: what can be done to heal this broken relationship? A reader of my last post (about viewing patients from a different perspective) asked me point blank: ”Dr. Rob, for the 99.999% of us who do not have a primary care doctor who is thinking as progressively as you, what advice can you give so that we can get our doctors to be treating us in the manner in which you are treating your own patients?”
I must admit, I get a bit uncomfortable with this, as it sounds like I am putting myself above my colleagues morally. Ironically, it is my deep understanding of my own huge flaws, coupled with an upbringing that scorned conformity, that rips me away from the survival self-centeredness most docs eventually adopt. Putting myself on any moral high ground only invites a very public (and deserved) fall back to the low ground I usually inhabit. No, I’m also not putting myself down out of false-modesty; I’ve made peace with my flaws, embracing them for what they are: a lens with which I can understand my fellow human scum-bags. Of course, as my best friend (and best man) used to remind me: “remember, I am doctor scum bag to you.”
Now, I don’t lay the whole problem at the feet of the fallen nature of mankind. I believe that our system of “health care” doesn’t just fail to counter the flaws of our nature, it actively promotes bad relationships. It does this by:
- Reducing patients to “problems.” The payment system requires we use “problem codes” to classify patients and justify visits. The problem-oriented approach is not just a byproduct of the payment system, though, it is at the very core of medical education. Despite a 100% ultimate failure rate, we are still taught that death and disease are the opponents we need to outsmart or out-procedure. Perhaps its analogous to the public infatuation with the tawdry and grotesque (the more gruesome the murder, the more news shows cover it), but we physicians love “interesting cases.” But nobody ever wants to be an “interesting case.” Ask any of the people who commented on the blog post. Boring is better.
This, apparently, is a map of my mind. It’s a little shocking to find out that my mind looks like a sea creature, a bug, or perhaps a vegetable. Actually, “Rob’s mind” and “vegetable” are often used in the same sentence.
Someone suggested to me that I may benefit from mind mapping. I don’t know how to describe it, but I think spatially; I see things abstractly as if I am pulling up from the ground and getting an aerial view of things. I write that way, I solve problems that way, I even play music that way. Maybe it’s tapping on the right side of the brain that is about nuances or about how things relate to other things in proximity or direction. Like I said: it’s hard to describe.
Anyhow, I was thinking about task-management with my patients, wondering what’s the best way to think about it and what is the best design for a system helping with this. Task management is perhaps the most important thing in health care that’s never talked about. Maybe that’s because it makes doctors feel less special, reducing our “magical” knowledge and “miracle” cures to algorithms and checklists. Personally, I take great comfort in systems because they assure me I am not going to forget important things (like setting a reminder to take the trash out on Sunday and Wednesday nights).
It feels dangerous to write this, but…my practice seems to be working.
I am now running and hiding from lightning bolts, meteors, or stray arrows shot in the air by a Scottish soldier. I am also expecting a raid on my office by the IRS, CDC, and BBC tomorrow morning. I don’t know why I wrote that.
But as afraid as I am to admit it, the thing that was once just a good idea is now actually growing and improving. We are up to about 300 patients (with a big infusion when a local TV network did a story on my practice) and have enough money to pay bills without a visit from uncle bouncy. While we’ve started to discuss when we will hire another staff person (probably a nurse), neither me nor my nurse Jamie (may her name be ever blessed) feel overwhelmed at this point. We can handle this volume, which speaks well for the future when we actually have a fully-working system.
The past few weeks have been totally consumed by my need to have an underlying system of organization. After fighting valiantly against the idea for the first two months, I succumbed to the necessity of building my own IT system and have been seeing the many benefits of that decision. Despite being totally obsessed with how data tables connect and whether I’ve left a parenthesis off of a script I’ve written, I now have a place to put data, have a pretty decent task management system, have an integrated address book, and have discussed integration with my phone system vendor, my secure messaging developer, and a lab order/result integration vendor. I’ve also found some strong local tech talent who gets what I am doing and yet doesn’t simply see the market potential for my software.
The reality is, my whole focus is on the practice model, and that model seems to work. As my business and medical care management systems click into place and become more functional, growing the practice should not be a problem. We continue to get several new patients signing up every day, and now the reluctant spouses of establish patients are joining (which is a very good sign – for both my practice and for their marriages).
Let me appease the gods and state clearly that this is by no means a sure thing. There are many, many things that could go wrong. A successful start-up requires not only a good idea and hard work; it also needs requires luck (or at least to avoid bad luck). I could get cancer, my building could burn down, or our city could be overrun by a mob of psychotic llamas. We all know the llama apocalypse is happening; it’s just a question of when, not if. So I accept the fact that I am, to a great extent, in the hands of the fates (and llamas).
There was a hole in the wall of our bathroom that was a painful reminder of a bad encounter with a plumber. Yes, that hole has been there about a year, and it has been on my to-d0 list for the duration, daring me to show if I inherited any of the fix-it genes I got from my father. Why not hire someone to come fix it? I also got (as I mentioned in my last post) dutch genes, which scream at me whenever I reach for my wallet. So this hole was giving me shame in surround-sound.
I attempted to fix it the hole last year, even going to the degree of asking for a router table for my birthday. Since there was previously no way to get to this all-important access to the shower fixture without cutting through the sheetrock, I decided I would take a board, cut it larger than the hole, then use the router to make a rabbet cut so the panel would fit snuggly. Up until then, I thought a rabbet cut was a surgery to keep the family pet population under control, but my vocabulary was suddenly expanded to include words like rabbet, roundover, chamfer, dado and round nose. Unfortunately, my success only came in the realm of vocabulary, as I was not able to successfully master the rabbet cut without making the wood become a classic example of the early american gouge woodworking style.
I am not sure why, but something inside me told me today was the day to give this another shot, and to my shock (and that of my family), I was successful!
This home project is actually a late comer to the DIY party I’ve been holding for the past few months.
- Don’t like your practice? Build your own from scratch!
- Don’t like the health care system, build a new one!
My latest DIY venture is in an area I swore I’d not go: I’m building my own record system.
I remember going to see the movie “Oliver” in the theater when I was a kid. Since this was my first movie in a theater, my mom made me a treat: a bag full of raisins and chocolate chips (Raisinets for Dutch people) and sent me there with my sister. It was a fine film, with Oliver getting kicked out of the orphanage when he wanted more gruel, the dastardly Bill Sykes threatening Oliver and sweet Nancy, the funny and clever artful dodger and Fagan teaching Oliver about life on the street, and with (spoiler alert!) good overcoming evil in the end Oliver getting adopted by a rich dude so he can get all the gruel (or real Raisinets) that he wanted. And though my memories of the movie are still vivid, my strongest memory was the look on my sister’s face when I walked out of the theater covered with melted chocolate chip goo. It went into family lore (and wouldn’t have happened if they had sprung for Rasinets, I might add). I think they still don’t trust me with chocolate chips.
The key line in the film comes when Oliver loses a bet and goes up to the gruel-master and says: “Please Sir, I want some more.” Which, as I am sure Oliver expected, causes the gruel-master to break into the song, “Oliver! Oliver! Never before has a boy wanted more!” and the whole dining hall to pull out musical instruments and singing harmony to the gruel-master’s admonition.
I can see why Oliver was scared. A whipping is welcome compared to his whole world breaking into song and dance.
Asking for “more” has caused trouble over the ages. Adam and Eve wanted more food choices, the people of Pompeii wanted more mountain-side housing, Napoleon and Adolph Hitler wanted to spend more time in Russia, and America wanted more of the Kardashians. We can all see what destruction those desires reaped.
Americans have been viewing health care the same way, always wanting more: more antibiotics, more technology, more robots doing more surgery, more expensive treatments for more diseases. The result: health care costs more in America than anywhere else. Some folks think that our “more” approach makes our health care “the best in the world,” after all, where else can you get so many tests just by asking. MRI’s for back pain, x-rays for coughs, blood tests for anyone who dons the door of the ER. ”Tests for everyone!” shouts the bartender. “Tests are on the house! ”
It’s been a long time since I wrote a post. My life, you see, is incredibly dull and boring. There has been so little to write about that I’ve been at a loss.
No, actually that’s a load of crap. It’s become a fantasy of mine to have such boredom. In reality, my life is as un-boring as it could be. It’s like the part of a story where everything is in flux, where little decisions have huge consequences, and where the inflection point between a comedy and tragedy is located.
So how’s my new practice going? In some ways things are going about as well as they could. My patients are amazed when I answer their emails or (even more surprisingly) answer the phone. ”Hello, this is Dr. Lamberts,” I say. This usually results in a long pause, followed by a confused and timid voice saying something like, “well…uh…I was expecting to get Jamie.” Yet I am often able to deal with their problems quickly and efficiently, forgoing the usual message from Jamie to get to the root of their problem. It’s amazingly efficient to answer the phone.
Financially, the practice has been in the black since the first month, and continues to grow, albeit slowly. The reason for the slow growth is not, as many would predict, the lack of a market for a practice like mine. It’s also not that I am so busy at 250 patients that growth is difficult. In truth, when we aren’t rapidly adding new patients, the work load is nowhere near overwhelming for just me and my nurse. In that sense I’ve proved concept: that it’s not unreasonable to think I can handle 500, and even 1000 patients with the proper support staff and system in place.
Which brings us to the area of conflict, the crisis point of this story: the system I have in place. The hard part for me has been that I have not been able to find tools to help me organize my business so it can run efficiently.
I’ve been going about this all wrong.
It’s not my dumping of the payment system so I can focus on care over codes, my use of technology to connect better with patients, or my vision of the “collaborative record” that is wrong. It’s the fact that I am doing this without my most important resource: my patients.
I realized this while driving in to work this past week. My first patient was a tech-savvy guy I’ve known for a long time. Not only does he know me, and knows more than me about technology, he also is a regular reader of my blog (bless his heart)…and he still chose to switch to my practice! So I was looking forward to running some of my ideas by him to see if my thoughts have strayed to the land of silliness (which they often do) or if I am actually onto something. This line of thought led me to think about collaborating with him to work on my IT vision, since he does work for an IT company. My line of thought then careened into the brick wall of the obvious: why just him? I’ve been getting suggestions and offers for help from many of my patients, who are clearly intrigued by my direction and desirous to lend their expertise on the project. So why not involve any of my patients who want to be part of this project?