Physician time means nothing to programmers and policy makers

I have been a way from blogging for a a bit and tried to clear my head a bit with a vacation skiing.  I left the computer at home, disconnected (as best I could), and had the luxury of feeling the knees working less fluidly than they had before, but still had some fun for a brief 3 day stint.  It was nice to notice that there’s a whole world out there — beautiful mountains, fresh air, nice friends.  All things considered, I am pretty lucky to have a stable job, appreciative patients, and a fulfilling career.

But it didn’t take long after my return to work for me to feel flooded again.  Two days after returning to work, it was like I never left.  Perhaps it’s like that for most busy folks, but somehow the world of health care delivery feels more frenetic than ever.  The inbox messages,  the mountains of results, the rescheduled patients on top of those already scheduled, the seemingly endless phone and e-mail messages, the late-night consults after a full day of procedures — all demanding time — it’s bordering on crazy.  I have several nurse practitioners who assist, but the volume of electronic patient care that’s happening now is overwhelming to even the most computer-savvy of us doctors.

And all of this communication is not compensated.  There are no RVUs for answering an e-mail.  There are no RVUs for speaking on the phone.  There are no RVU’s for typing.  No RVUs for data entry and clicking a mouse.  Physician time means nothing to programmers and policy makers.

It’s a larger symptom, I think, of the new efficiencies built into the electronic medical record (EMR) that has become ubiquitous with the world of medicine today.  Information flies so fast and there’s so much of it that it’s getting almost impossible for doctors to keep up with the screen responsibilities, not to mention their care responsibilities.  The EMR is no longer just an EMR.

The EMR has morphed into  a scheduling agent, pharmacy, reminder pad, calculator, care pathway generator, instant messaging service, a procedure orderer-by-proxy (and guideline) and a patient messaging portal that, aside from a 400 character limit, provides unprecedented  access to physician in-boxes and schedules. There are so many buttons that they no longer fit on a single screen and the allergy field no longer can be displayed as it’s pushed out of the way by the name of the patient’s insurer.

Add to this the constant and growing influx of patients (thanks to marketing pushes and programs to spur referrals), voluminous administrative meetings, and growing CME requirements, it’s no wonder many of us feel flooded.  I work later than ever now thanks to these electronic efficiencies, then find myself waking in the middle of the night wondering: Did I call Ms. Smith? Did I miss something? Did I put that order in? When am I going to do those result notes?

I think I’m suffering from post-traumatic electronic overload disorder (PTEOD).

Oh sure, we could hire another guy or gal to offload some of the work — maybe even hire a wasteful manpower-intensive scribe like those that work in some ERs that click for cash – but that really won’t help stem the ongoing barrage of information that is now pummeling physicians and their care teams at an unprecedented rate.

Sadly, I don’t see this trend changing anytime soon — the business case for the EMR is just too attractive for hospitals and payers.  Still, with the prospect of ICD-10 and it’s 71,924 procedure codes and 69,823 diagnosis codes (that must be paired correctly lest doctors not be paid) just around the corner, I fear that physician stress, burnout and PTEOD will only increase as we are force-fed this diet of electronic overload without any reflection of what its doing to those who provide the care.

I need another vacation.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • JR

    http://dilbert.com/strips/comic/2001-04-14/

    Truthfully, most programmers are given a list of things to do (requirements) that they execute. This means someone else decides what the computer program will be like and what it will do. Usually they’ll be given a list with “billing” as the highest priority, so the product comes out with billing as the focus of the product.

    If you’re a private practice doctor or a management type who gets to decide which EMR to use, ask “how many usability specialists do you employ?” While there is no guarantee that having usability specialists will mean a product is easy to use, if they don’t have usability specialists, do not buy their product!

    • drma

      Thank you for this comment. I love asking about usability. It is a great way to make sure things work like they should and so few places use them.

  • uDRAKSh2L5

    I agree with your comments almost in their entirety, except that you’re pointing your finger in a slightly mistaken direction…
    The issue isn’t programmers – they’re writing code to specifications set by others. And policy-makers aren’t directly responsible for the mess that EMRs have become, although they certainly have enabled/allowed some or all of the problem.
    The real problem, though, is the insurers. On the one hand, they support the policymakers, or even push them, regarding the inane/insane measures such as ICD-10. Insurers like it when medical coding is outrageously complicated – they have thousands of employees specifically to deal with that complexity, they know how to use the complexity to their advantage, and they know how to put providers at a disadvantage. Even the largest hospitals/health systems have mere hundreds of administative folks to counter the onslaught of the insurer hordes.
    Likewise, insurers have a concentration of “free speech” (i.e. $$$) which allows them to outlobby just about any other healthcare segment except pharma. Laws that reduce physician autonomy, allow economic exclusions/exceptions to various policies, that allow payment reductions, clawbacks and many other forms of financial chicanery have all been passed with the initiation, blessing and support of the insurance industry at both the state and federal levels. Again, anti-trust law ensures that no provider organization can match the insurance industry in a high stakes lobbying fight to see who can buy the most congressbeasts.
    So – you’re right; medicine is a hellsih pile of steaming administrivia. But don’t blame the programmers, and at least give the policymakers a trial before you string ‘em up – they are far from the worst of the bad guys.

    • NewMexicoRam

      So right.
      Insurance, with the attorneys, rule.
      I’ve about given up. I’m only 54, nowhere near retirement, but I see myself as a timeclock puncher now, just a clerk.
      I go to work with a cold face, try to smile for patients, and just try to survive.
      And my family suffers for my late nights.

      • buzzkillerjsmith

        You gotta get outta there, man. You don’t want to become dysfunctional. You don’t want to die young or ruin your family.

        I’ve had two exceedingly nasty jobs, both for CorpMed, both well-paying, both horrible experiences. When I worked at Kaiser, the CorpMed kingpin, several times per day I would go into the men’s room, splash some cold water on my face, look in the mirror and say, ” I hate this @#$%*^! job.”

        When I quit all that went away. Only took about 2 weeks to get back to my usual self. I have given up a million or two bucks leaving Kaiser, what with the higher salary and better benefits I left. Best thing I ever did.

        • guest

          My interview at Kaizer several months ago was ridiculous. It reminded me of a Kafka novel. I was taken through convoluted hallways of a massive building with admin only. Waited in a lonely room for half hour. Some secretary came, asked me if I am familiar with EPIC and how fast I type. Signed some paper indicating this. Three old docs show up, tell me how Kaizer is the future. Lunch, the interviewing doc drops the bomb: ” You need to sign a contract today or you do not get the job”. I said no, the pretty young MBA person with us tries to investigate, “why not, how is your husband, are you planning kids?” The doc I interviewed with after that said later that week to me that she is planning on leaving because she is exhauster of being followed, measured, compared, demoralized and mistreated…

          • Deceased MD

            That was hilarious comparing Kaiser to Kafka. Unfortunately, I think it is a fair comparison these days. Are you sure you were not applying for secretarial work? LOL (Sorry just kidding with EPIC and typing it’s a bit much.)

          • buzzkillersmith

            Speaking of Kafka, Kaiser has set up a thing in Wash. DC called the Institute for Total Health or something like that. Total.

          • Deceased MD

            Is this their lobbyist group’s name?

          • buzzkillerjsmith

            I assume so. It’s called The Center for Total Health and has a fancy website. It’s on Second St. NE, which, if I read the map correctly, intersects K Street.

            If you wish you can go to the website and join the “conversation.”

          • buzzkillersmith

            That interview sounds worse than mine. Of course mine was 25 years ago. But it’s good to know that some things in the world don’t change much. BTW, which Kaiser did you interview at? Mine was northern California.

            EPIC. Sweet. Didn’t EPIC go down for a few days straight at Sutter in CA?

          • ssilverstein

            “You need to sign a contract today or you do not get the job” is on its face improper if not illegal. Just on the basis of denying you the opportunity to have the “contract” reviewed by an attorney alone.

            If it had been me, I would have said that to the person’s face and taken my leave.

          • guest

            Thank you. This makes me feel better. They called and emailed to see if I would change my mind. Finally, a week later an email came that a position had been filled. Somebody signed on the spot. It still feels strange that this is their normal practice. Also, why would they bother telling me the position was filled, as if they wanted to tell me I made a mistake. Very unprofessional.

          • ssilverstein

            Unprofessional? Perverse is a better term.

    • ssilverstein

      Re: the insurers, well, CRICO’s certainly learned its lesson. See http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html

  • guest

    I told a recruiter 2 years ago I was looking for a part time job for reasons you describe above. He never called again. If you want the recruiters to stop calling just tell them you are only considering part time. I do not mind being paid less. So I was ok with less pay and undesirable location and yet could not find a job where I can work 40 hrs/wk. I am still looking, here and abroad. Why is this?

    • buzzkillerjsmith

      I get calls all the time asking if I want to work in the urgent care in some Godforsook nowhere –part time, full time, standing on my head, whatever. Are you in family med?

      • guest

        No, hem/onc. The only way to take vacation is between jobs or locum tenens work…

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    It’s called productivity, and it has been going up at unprecedented
    levels for all American workers, including the miserable “programmers”
    who inhabit the same type of world as described here, with the added
    catch that if they can’t produce massive amounts of work 24×7
    for a pittance, someone on another continent will be more than happy to
    do just that.
    Medicine was spared such labor related indignities for a very long time, but those days are over, and yes the EMR is the tool by which individual doctors are turned into a labor workforce for corporations.
    The longer you guys let this exploitation continue, the less likely it is that you will ever be able to turn the tide….

    • guest

      My sister-in-law, a previously fairly conservative Republican who is also a commercial banker said to me yesterday, “I feel like there’s this entire level of middle management that has sprung up and you’re on the treadmill and their only job is to keep turning up the speed on the treadmill. And if we got rid of them and used the money to pay for more bankers to actually do some work everyone’s lives would be easier.”
      That was interesting to me, because I have had very similar thoughts about what’s going on in the healthcare industry. Also, I agree that it has been going on for a long time in other industries, now that I am paying attention.
      To me it seems like the only viable answer is unionization? What else can be done?

      • buzzkillerjsmith

        Excellent point. I’ve been thinking about unionization for a while now. I don’t understand why employed docs don’t do it. Starve a feeding hospital administrator.

        • Patient Kit

          A lot of Americans buy into the myth that they can always get a better deal for themselves individually than they could get as part of a group. Three guesses who created that myth. But the truth is that going up against any powerful entity, be it an employer or a health insurance company, you’re always going to have more power as a group than you will individually. Doctors are not alone in thinking they don’t need a union. But perhaps doctors, more than other professions and workers, have felt above unions. Actors, pro athletes, teachers and airline pilots know the value of a union. And so do many nurses. So, it’s not just a class issue.

          Doctors, by the important nature of your work, should and could be more powerful within our healthcare system if you stuck together in any organized politicized way. As a patient who values good doctors, I hope it’s not too late for you to become a more powerful force within what has become a really big business. Big Pharma is just one part of Big Health. And you can’t fight that alone. No matter how good you are.

          • buzzkillerjsmith

            Agree 100%.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Agree with Buzz, Excellent idea. A national physician union is probably the best answer and it should include “independent” physicians as well, since compensation for their labor, and to a large extent working conditions, are also dictated by others.

      • Deceased MD

        Thank you for that insight. I would not have guessed it about banking. Any ideas why that has occurred in their world? I also sense that there is no value to many admins jobs and it just sucks the system dry. It is funny how people make fun of gov’t workers but in the end now private industry-including medicine of course is full of useless people and jobs with no value.

    • Deceased MD

      I agree with you. i think there are more docs turning to politics for just this reason of excessive regulation and it is turning medicine into just a bunch of robots.
      Speaking of programming, I was just at a nice hotel and before I left I was displaced by some Big Pharma group. Unfortunately overheard part of their project. Programmers determining the most effective cost of their new drug given a set of dubious parameters. Right next to their expensive feast.

    • Patient Kit

      I agree that the extreme exploitation of the American workforce has been escalating for years. People tend to only get politicized about it when it effects them personally and they really start to understand it as something real and not some abstract concept that happens to others. And then it’s hard to get demoralized people to feel like doing anything to try to change it isn’t already useless. Plus, it is hard work to fight the machine. And some sacrifices are necessary. You don’t have to give up being a raging individual when you become part of organized group though You can be both at the same time.

    • ssilverstein

      Re; “The longer you guys let this exploitation continue, the less likely it is that you will ever be able to turn the tide….”

      Indeed.

  • buzzkillerjsmith

    1. EHRs are lead pipes to the brain. Everyone knows this, or at least everyone at this blog.

    2. Going on vacation makes no sense because the pleasure of going away is dwarfed by the pain of coming back. You should know this by now, Dr. F. Just say no to vacations.

    3. Good news and bad news. You are in a world of hurt, but at least in primary care we have a solution. It’s called the PCMH. We will be soon sitting back in our easy chairs while other people–NPs, PAs, nurses, MAs, pharmacists, reception and so on do every little bit of our work. Shangri-la, baby.

    I’m planning on training the MAs up in managing chest pain and hypotension. They’re excited and so am I. Perhaps you should consider training yours up in cardiac cath. How hard could it be?

    • Deceased MD

      OK Imagine this Buzz. Just went on a brief vacation only to meet a woman who “teaches doctors”. I had to get out of the hot tub! What else does she “teach”? Yes. The subject of this blog.

      Only to find there were 40 of these EHR consultants from Alabama descending this hotel. One said he was previously a truck driver that distributed bottled water in the midwest and the other was from Oklahoma and his hunting dog maimed his brother-in-law who just got back from prison. They said these EHR companies are searching for anyone who can learn their system to teach. No credentials necessary at all!

      To say the least I left the hotel only to be displaced for lunch by some Bg Pharma group having the most expensive feast.

      • buzzkillerjsmith

        I love it. See, that’s what happens when you go on vacation.

        • Deceased MD

          If you love that I have to share the finale. The Big Pharma folks as they were feasting were devising a program simply to evaluate the most efficacious cost of their new drug taking into account various meaningless parameters.LOL. Seriously don’t go on vacation. It was relentless!

    • Patient Kit

      I’m new around here but I’m beginning to get your very dark sense of humor. :-D

    • ssilverstein

      How hard could it be? No harder than performing nuclear fission on your kitchen table…all you need are the right tools. (Scott Adams)

  • Deceased MD

    So what you are saying is that Americans live in a world that rivals Orwells. LOL. And is run by a bunch of megalomaniacs. Seriously thank you so much for your input. Explains a lot.

    • guest

      I think Arby is right. At my previous job as an employed physician at a “non-profit” hospital chain, I was told that I was “too detail oriented” for questioning things like why one specific physician was allowed to reserve 6 weeks of vacation time for herself during the summer, leading to the rest of us being told that we wouldn’t be able to take any vacation that summer. Or, why the call schedule was not evenly divided among all of the physicians. “Too detail-oriented.” Apparently, that’s a bad thing in a doctor these days.

      • drma

        It starts early. In residency. I complained that I was given more call than anyone else. The chief resident created a summary of call schedules that showed I had only one or two more calls than the rest of the group. But he only used 6 months of my schedule and 12 months of everyone else’s schedule. Obviously I am one of those too detail oriented complainers.

      • ssilverstein

        “Too detail oriented?”

        Perhaps you should have told the person saying something that bizarre that you would report to their superiors they were clearly under the influence, babbling nonsense.

        Of course, then you’d have been labeled a “disruptive physician”…

  • Deceased MD

    Oh I take you seriously. Sorry if that did not come across. It is very exploitive for sure. I fully believe you. One sees this at just about every turn these days. thank you for sharing this as most of us don’t realize this sort of thing happening at banks.

  • T H

    Why blame the programmers? They write the code that the policy makers and upper level management (insurers, CMS, etc) demand. MDs are merely the sweat labor.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I’ll go for Visio and Excel, but SharePoint?? :-)
    Seriously now, of course medical software can get better, but in order for that to happen, it needs to follow the same path as all other commercial software, i.e. some of us struggle with the prototypes, make them better and better, and then and only then, everybody else jumps in to enjoy the fruits of our frustration.
    EMR is taking a different path because its original purpose has been co-opted. None of those productivity tools you mention were/are intended to collect data about the user. and/or his/her customers.
    EMRs are being morphed into surveillance tools and if you look at the latest “meaningful use” mandates, they look awfully better served by a plain keylogger than anything else.

    • doc99

      Actually, EMR’s seem to have sprung from the entrails of billing software. Who cares about actual patient care? Just make sure you capture all the ICD & CPT’s.

  • buzzkillerjsmith

    Uh, where did you go to medical school, again?

    Medicine is a personal service profession in which our time and effort are best spent on diagnosis and treatment, not on data entry.

    Comparative advantage is not a new insight. David Ricardo went over it in the 19th century.

    I teach med students, so I feel comfortable giving you homework, young buck. If you wish you be taken serious at this blog, you will do it correctly. Explain, using either algebra or arithmetic, comparative advantage, and explain how it relates to this discussion. Due Monday.

  • Arby

    “Work smarter, not harder”. Another meme used in business that kind of proves my point. It isn’t that technology cannot be helpful, I have seen the elegance of a well written program, no, it is rather that paying 100′s of thousands of dollars for software means that they can justify (actually have to justify to the bean counters) giving you the work of three people while the average piece of software saves you the work of about half a person. And that, never when first rolled out; it costs you more time with the learning curve and every iteration is another learning curve.

    After understanding Deceased MDs perspective, I found his naivety about banking a bit endearing, yet I am a little baffled by yours. Do you understand how business thinks? Their software will only improve for you when they see you as the customer. Right now they have beguiled or coerced the purchase of their products by healthcare institutions but they write for their actual customers, the insurers and government. Once either healthcare administrators feel the pain of poorly implemented systems and raise a huge stink and/or if EMR companies can’t keep selling upgrades based on what insurers and government want (almost impossible since I think what they want never ends), then they will start to pay attention to what the healthcare workers need.

    I don’t disagree with you that the software has the ability to mature into a better product, just that I think it will be a painful process and it will cause a lot of collateral damage on the way there.

    Somewhat OT:
    I was at the Endocrinologist today and she didn’t know how to access a calculator in the medical university’s system (some version of Epic). We had to calculate doses of Levothyroxine on my iPhone.

    Question for anyone, is a calculator a standard offer in Epic or is it the practice to back out to Windows to use the calculator there?

    Note that I have only worked with the Meditech Pharmacy module and at that time (10 years ago) I don’t recall an embedded calculator. But, we did have the option to back out to Windows or the internet to use one.

    The system also choked on additional directions for a Rx reading “an extra 50 mcg on Tues/Thurs and an extra 25 mcg
    on Sunday” (yes, I am complicated) in what I thought was a free text field. Took a few minutes to finally get something the computer would accept: no wonder it is frustrating for many of you.

  • doc99

    And they call Medicine a “Learned Profession.”

  • buzzkillerjsmith

    I rest my case.

    • Preston Gorman

      Thanks for your insight.

  • ssilverstein

    Preston, I saw this comment today via a Google alert.

    I will say that “positive attitudes” and “patience” are an extravagance in 2014 regarding a decades-old unregulated technology, in the face of recent revelations from CRICO that a significant percentage of their annual med mal cases in Massachusetts were related to health IT problems.

    (CRICO is the Harvard medical community’s med mal insurer – yes, Harvard, one of the most skilled users of health IT in the world.)

    See

    http://hcrenewal.blogspot.com/2014/02/patient-safety-quality-healthcare.html

    and further observations at:

    http://hcrenewal.blogspot.com/2014/03/some-inconvenient-observations-for-our.html .

    Instead of “positive attitudes” and “patience”, I suggest critical thinking and action.

    p.s. – Is that a “full blown assault?”

  • ssilverstein

    Dr. Fisher,

    Re: “The EMR has morphed into a scheduling agent, pharmacy, reminder pad, calculator, care pathway generator, instant messaging service, a procedure orderer-by-proxy (and guideline) and a patient messaging portal”

    Indeed.

    I have written that the terms “EHR” or “EMR” are anachronisms. What we have today is not an electronic file cabinet these innocuous terms suggest, but computerized clinician and clinical resource command-and-control systems, especially within healthcare organizations. Increasingly, almost every transaction of care must be mediated by these systems.

    They need to be treated as what they are. The “EMR” terminology fogs the understanding of these systems and their impact on care and physician workload and stress by laypeople.

    See the last slide of my post at http://hcrenewal.blogspot.com/2012/08/my-presentation-to-health-informatics.html that illustrates the point.

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