Click, click, click: How can I help you today?

Click, click, click, “Hello, how are you today?”

Click, click, click, “How long have you had a sore throat?”

Click, click, click, “Have you had a fever?”

Click, click, click, “Have a seat on my exam table, please.”

Click, click, click, welcome to my day.  Let me introduce myself, I’m a professional clicker.  I used to be a member of a highly respected and sought after profession; a doctor.  The modern world of government/insurer managed healthcare has turned me into an efficient clicker, busily documenting everything I do so that I can:

  • Be reimbursed for my services
  • Afford to pay my staff/landlord/utility/self
  • Avoid being prosecuted for fraud by Medicare
  • Avoid lawsuits
  • Communicate with other docs
  • Meet “quality” parameters set by Medicare/insurers

Being highly educated, my colleagues and I are easily trainable and have reached the pinnacle of “clicking.”  Now, Medicare and the New York Times are on the attack.  They are questioning if docs are “gaming” the system to receive higher pay.  They are questioning our ethics.

First of all, we did not create the system/game.  At every step of the way, we have been forced to play by Medicare’s and the insurers’ rules.  Not only have we been forced to play by their rules, we have also been forced to shoulder the expense of buying and learning to use the EMR (electronic medical record) that many of us did not want to use.

Second, the EMR made it easy to record what we never recorded in the past.  It’s hard to exam a person without examining his/her skin.  Acne and blemishes, skin color, texture and warmth are readily apparent.  In years past, only positive findings would have been recorded in my patient’s paper chart.  Now, click, click, click and it’s all recorded electronically.  In the old days, I knew what my notes meant.  Now, the rule is:  If it’s not recorded, you didn’t do it.

Click, click, click,  and everything I do is recorded.  Every click satisfies the rules Uncle Sam and the insurers of America have forced down our collective throats.  Does all the clicking improve medical care?  I think not.  Has all the clicking saved money?  Most definitely, it has not. Am I making more money?  Definitely not.  The upkeep and expenses associated with clicking is immense.

So, who profits?  No one.  If no one profits, why are we doing it?  We are clicking because we are being forced to click.  In 2014, we will be financially penalized for not clicking.  Now, we may be penalized for being too good at clicking.  The government is on a witch hunt looking for fraudulent clickers.  Sometimes, you can’t win.

One more question needs to be answered.  Clicks are data points and are being collected every minute of the day by Medicare and the insurers.  What’s being done with all that data?  That question is the one keeping me awake at night.

Click, click, click, “Good morning, how can I help you?”

Stewart Segal is a family physician who blogs at

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  • Dike Drummond MD

    The job is never over until the mouse work is done … eh? Healthcare documentation is the very definition of a “necessary evil” and I do love your free floating paranoia there at the end.

    Having come through my residency prior to EMR, I must say it is an improvement over the mystery of a hand scratched note or the tangled web of a dictation that never gets to the point.

    Since the beginning of time doctors have hated their documentation method. It is one of the top 5 sources of stress for the doctors I work with and it is NEITHER a vast conspiracy or a reduction of your skill set to a mere secretary to the big data gathering machine.

    What most doctors do is demonize their EMR and refuse to learn how to use it well. They remain a victim of it … and allow it to control their emotions for large swaths of the day. Become a power user. Actually study it …use the templates and checklists … study the reports to get better at what YOU do … game that system baby. Better yet, give your staff responsibility for as much of the data entry and notes as possible – even to the point of your nurse/MA staying in the room and scribing your visit so all you have at the end is a sentence or two to enter.

    You have to chart, this is the method du jour … oh … and YOU can use that data too you know.

    Dike Drummond MD

  • Randall Oates, MD

    So sad that doctors are mostly implementing approaches to EHR that either turn them into distracted data trolls or gives them hours of extra homework. Typically, the other alternative they follow is for them to “learn how to use the EHR” so they can more quickly insert globs of potential garbage (cloned data or templates of which not all is validated). Alternatives are available where the only action that is necessary is a single click to sign off patient documentation at the end of the encounter. The documentation can all be created by real-time, remote super-scribes, but obsolete EHR systems and old habits die hard.

  • Docbart

    No one can force you to use EMR if you really don’t want to. I don’t. So, if Medicare dings you 2%, how much will that hurt, compared to the expense and lost productivity of using EMR? If you can’t figure out how to get the 2% back, you’re not trying hard enough. Thank Newt Gingrich for this misguided effort, BTW.
    I know what you mean about wondering how all this new data will be used. I still can’t figure out what positive outcomes CPT codes have actually produced, other than creating a cottage industry centered on coding. In NJ, all physicians had to take the time to be fingerprinted, at their own expense at the offices of some contractor. I have yet to hear about anything productive coming out of that.

    • southerndoc1

      Bingo. The career of any physician is a limited number of years: every year she sticks with paper is one less year being miserable using EMRs.

      • Randall Oates, MD

        Every year on paper is another one of having to work increasingly harder in order to just maintain economic viability, and it is another year closer to obsolescence.

        • southerndoc1

          Not true. Right now, every year we stick with paper is another year that we leave the office earlier and take home more money than 95% of the primary care docs in our community. IF and when that changes, we’ll reevaluate.

    • Randall Oates, MD

      Realistically, EHR use and “Meaningful Use” could well become mandatory.

      1. Medicare and Medicaid Penalties start in 2015

      2. Other payers adopting MU components -Four major insurers (Aetna, Highmark,
      United Health Group, and Wellpoint) announced that, at a minimum, they will
      link their pay-for-performance programs to federal meaningful use criteria.
      Other insurers are likely to follow.

      3. NO MU = loss of board certification – The American Board of Medical
      Specialties (ABMS) released a statement in August saying that they intend to
      link meaningful use of health information technology into the ABMS Maintenance
      of Certification© program.

      4. Emerging state initiatives to require MU – the state of Massachusetts may
      take away the license to practice medicine in 2015 unless demonstrating
      meaningful use of an EHR system. In Maryland, private insurers will be required
      to build incentives for acquisition of EHRs and penalties for not adopting them
      into their payment structure.

      Is it probably time to either start transitioning to a Direct Care or Concierge
      model or adopt one of the emerging approaches that allows for EHR and data
      management in fashions that enhance rather that detract from the doctor-patient

      It is better to light one candle than to curse the darkness – Chinese Proverb

      • southerndoc1

        Despite a lot of internet chat, there’s no evidence of either licensure or board certification being linked to MU. Making decisions out of fears of what may happen at some undetermined point in the future usually ain’t good.

        • Randall Oates, MD

          For the docs that don’t intend to become obsolete and bankrupt, there are several choices to be made now.

          Track #1 – Probably 10-20% will be successful in a direct care or concierge, high touch model that will involve some nature of patient “subscription.” The doctor here will typically continue to spend a significant portion of their work time doing data entry and administrative tasks, but at least they are getting fairly paid for doing it, it is lower in volume, and it involves mostly familiar, legacy skills they already have.

          Track #2 – Probably 40-60% will initially continue on the current track of physicians as distracted data trolls on the hamster wheel of needing to see more patients while doing more and more of the necessary data collection at the same time. These physicians will eventually, either burn-out or live in increasing misery as they are pressured to work harder and not smarter chasing the decreasing revenues of waning fees for services. Their unfortunate bitterness is readily evident on all the blogs physicians tend to visit.

          Track #3 – Probably 10-20% make a transformation, and will be successful because they are focused on the ultimate high touch model of focusing on increasing the value stream to the patient and physician. I have recently visited dozens of practices where physicians are using the next generation EHR and workflow changes to recover 2-3 hours daily of wasted time (e.g. data entry and administrivia) to either see more patients or go home earlier (usually a balance of both) and delegate the capture of the necessary structured data in order to participate in ACO and other initiatives focused on quality measures, etc. Some are going home 2-3 hours earlier and others have increased their income by more than 6 figures. In most of these, there is far less physician work than when they were on paper/dictation seeing fewer patients. The satisfaction of patients, doctors, and staff are certainly way up. So, it is possible to be both higher volume and be higher touch with better doctor-patient experience; less physician work; and higher quality in all areas.

          After 2-3 years of mostly Track #2 for the majority, in order to take care of the 80-90% of patients not in direct or concierge care, Track #3 will become predominant out of necessity and survival of the fittest. This track will be delayed a bit because it requires very different I.T. systems, and thinking than what is in place in most healthcare settings now. Interestingly, most of the Track #3 doctor practices I have recently visited have been 1-2 doc, independent practices. Several of them are already enrolled in either comprehensive primary care initiatives or other emerging models that rewards them more for better, high touch care rather than volume.

          Time to make a choice?

  • Deep Ramachandran

    Of all the blog posts I have read on EHR from a physician perspective, (I’ve written several myself!) this is the most entertaining, and probably the most informative!

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