What health care can learn from Katz’s Delicatessen

What health care can learn from Katzs Delicatessen

Sometime during the last year of the second millennium, I wrote my last letter in response to the last letter I have ever received. It’s been email ever since. I don’t recall making a conscious decision to stop writing letters. It just happened. I cannot pinpoint the exact date when my work memos, agendas, proposals and various notes, disappeared from my desk as if swallowed whole by my laptop. They just did. I still have lots of papers lying around, but I recently noticed that I don’t have any pens.

Now, I will let you in on a little secret. I can’t type. I have written tens of thousands of lines of code, thousands of emails, business plans, presentations, contracts, white papers and blogs, typing with one finger. I like it this way. I use everything Microsoft Office has to offer, but only ten percent of functionality, or maybe even less, and I use it all day long. I don’t know anybody that uses computers the way I do. There are times when I have to interact with proprietary software that I did not choose, to complete tasks I don’t care about, and invariably, no matter how slick that software is, I hate it. Basically, I hate everything other people make me do.

There is a mantra that never fails to materialize whenever EMRs are discussed, which says that EMRs were built for billing, and that’s the reason why so many doctors dislike their EMR. I beg to differ. The template option of documenting a patient encounter was built for billing, but the remaining 90% of the EMR was not.

When you first open your EMR, what do you see? A list of today’s schedule? That wasn’t built for billing. A “to do” list? That wasn’t built for billing. When you select a patient record in your EMR, what displays on your screen? A “summary” page for that patient? That wasn’t built for billing. Everything you see on your screen when you prescribe medications, order labs, review results, send a task or a message to staff or patients, generate referrals, change your password, maybe take a blood pressure measurement here or there, was not built for billing. It was not built for billing because you don’t bill for any of those things, so it couldn’t possibly have been built for billing.

But then, most of what doctors do with EMRs is documenting encounters with patients, and when you get ready to do that, invariably the dreaded screen, full of checkboxes and drop down lists, opens up in its unparalleled glory. This was built for billing. Look at that screen a bit closer, and you will discover that everything that was built for billing is actually optional. You could type, with one finger if you wish, three sentences, and be done. In most cases you could dictate five sentences right then and there and be done. The computer is not going to detonate on your desk if you don’t click the “normal” box to load seventeen pages of PERRLA EOMI into the note, and the police are not going to barge through the door if you don’t choose medically necessary ICD-10 and CPT codes.

You could document your encounter precisely the same way you documented it twenty years ago, maybe using Dragon instead of a little dictation gizmo, and heck, you could use a pen on a piece of paper and let Mary “attach” it to the visit note later, because the EMR will let you do that too. You got paid before you ever laid eyes on an EMR template, and you will continue to get paid if you never use one.

You could use your EMR the same way I use Microsoft Office picking and choosing the ten percent that makes your life easier and ignoring the rest. And your colleague down the hall could choose a different ten percent that makes her happy, and we could all dispense with the drama.

Yeah, well, no, you really can’t do that. Why? Because “other people” are making you do things you don’t want to do, things you don’t care about, and they are using your EMR to enforce their will on you. And if you are anything like me, you will hate that EMR, no matter how much usability and functionality has been baked into it. This probably explains a good chunk of EMR dissenters, but it does not explain everything, because just like most things in life, righteous opinions have more to do with luck and random events than with absolute truths.

First thing to observe is that medicine is, or was until recently, a complex set of personal services. A personal service is a service provided by one human being to another, and as such differs greatly across endless dyads of people engaged in providing and receiving a service, and across the spectrum of services (think hairstyling). When you attempt to mediate a personal service with a canned computer program, you will find that sometimes the software fits in like a glove, and other times it fits in like an elephant in a china store. The rest is just a matter of degrees. Simple probability ensures that there will be doctors for whom a given EMR is perfect, in most cases right out of the box. If luck has it, and they happen to buy, or be given, that one EMR, they will be content. If in addition to lucking out on their EMR choice, their personal style of service happens to match those things that “other people” want them to do now with their EMR, you will have a bunch of very happy campers. And extremely happy campers have a tendency to turn into evangelists.

At the other end, you have the folks who drew the wrong fitting EMR, and whose personal service style is diametrically opposed to the new paradigms, sometimes to the point of completely eliminating EMRs from consideration. This group is where the prophets of doom reside, along with a silent majority keeping their heads down, constantly looking for escape hatches. In between the singers of odes to joy and those contemplating professional suicide, there are hundreds of thousands of physicians with milder feelings about this entire state of affairs, and some are eloquently vocal.

The ones I find most intriguing are the producers of bipolar and often schizophrenic narratives about the grim reality of being turned into “data entry clerks” by mandated use of technology that “is not ready for prime time,” while wholeheartedly supporting the speedy transformation of medicine into a big data business, which is the multifactorial silver bullet for all that ails humanity.

And this magic silver bullet is blocked from firing because of the second EMR mantra which states that EMRs “can’t talk to each other.” Presumably once EMRs begin talking to each other, physicians would be free to enjoy the wisdom of big data without the inconvenience of generating it. Sort of like having your cake and eating it too. Alas, big data’s elements are the building blocks of EMR linguistics and are a prerequisite to having EMRs talk to each other. Thus the agony of collecting mountains of structured data elements for payment purposes is being replaced now with the misery of collecting troves of structured data elements, which include, but are not limited to, what is required for billing. One would think that we could slow down and let technology evolve at its normal pace, and let doctors pick and choose how much EMR they want to have for breakfast, but we really can’t do that anymore, because we no longer control the process. Big data business does.

I just looked up from my keyboard and saw my son watching a TV program where folks seemed to be searching America for the best sandwiches. They were at Katz’s Delicatessen in New York. Katz’s Deli is a family business, established in 1888 and passed down through several generations. They make and serve pastrami exactly like they did in 1888. They even slice the meat with a knife instead of the latest slicing machine and insist that it’s better that way. Katz’s Deli, and the handful of other establishments like it, managed to survive the mass destruction of the mom and pop sandwich business by the mass creativity of Subway. Maybe they were lucky and maybe they were also a bit smarter. Every owner of every shop on that TV show was wearing an apron, serving customers and addressing them by their first names. Every owner, and every interviewed customer, said that deli meats are really about long term relationships and pride in handmade personal service.

During WWII Katz’s Deli began a tradition of sending salami to the boys in the army. Today, Katz’s Deli will “Send a Salami to Your Boy in the Army” straight from your computer screen, because Katz’s Deli has a website and you can shop online for some things. I am certain they have computerized cash registers too, but they insist on marinating, spicing and smoking and slicing every bit of pastrami by hand, right there on Houston Street.

See, Katz’s Deli uses computers like I do. They take the ten percent that seems useful, the ten percent that doesn’t alter the essence of their art, and never bother with the rest. And business is booming, because Katz’s Deli discovered the only way to survive Schumpeter’s gale (which by the way describes how capitalism dies by marching from crisis to crisis in a doomed quest for more thorough exploitation of the masses), and beat back the armies of creative destructionists with a stick. You have to be really good at what you do, and you have to want to be the best at what you do, and you have to carefully add a dash of good technology to bring your personal flavor out.

I’m going to surprise my boy now and order some handmade pastrami … Ess gesunt!

Margalit Gur-Arie is founder, BizMed. She blogs at On Healthcare Technology.

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  • whoknows

    Well put. They want a relationship with the customer that they can be proud of and be the very best. Unlike capitalism that can be the most exploitive. Case and point, I am in physical therapy at an academic center because it is a specialized area that I require. When my small number of visits are up with them, I just found out the cash price. Well first of all they have taken what usually is an hour or 45 minute visit down to 30 minutes. But the price? $300-$500 per session ($600 to $1000 per hour).and for a physical therapist NOT even a doctor.

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

      Is it the same as what the insurer paid for this too?

      • Patient Kit

        The fact that hospitals and other healthcare providers routinely charge patients not covered by insurance so much more than they routinely accept from most insurance is on my personal top ten list of most obscene aspects of the US healthcare system. How is it fair that, for the exact same theoretical service, they’ll accept $50 from Medicaid, $90 from Blue Cross but charge the uninsured $500? For the exact same service. >:-(

        • Dr. Drake Ramoray

          We actually have had the opposite problem. We offer a discount to self pay. A few of them have now gotten insurance with high deductible plans. The rate we have negotiated with their insurance company is significantly higher. These patients get very upset that they are now charged more which they have to pay because of high deductible insurance. This experience has been one of the things that has inspired me to move to a low cost direct pay practice.

          • Patient Kit

            Our healthcare system is all just so damned complicated and exhausting. No need to wonder why Dr Google has become so popular.

  • Deceased MD

    “And this magic silver bullet is blocked from firing because of the second EMR mantra which states that EMRs “can’t talk to each other.” Presumably once EMRs begin talking to each other, physicians would be free to enjoy the wisdom of big data without the inconvenience of generating it.”

    And here lies their vulnerability, because they won’t share. Most won’t accept any tests from other facilities, let alone sharing EHR data. They are in fierce competition of who has the biggest and the best. Bad pt care at best because they will only refer internally, not to the very best fit for the condition. And their greed. That will also be their downfall.

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

      I am not sure there will be any downfalls in the short to medium term, if ever. Greed has served big corporations well, historically, and I think it will do so for health “care” as well.
      As to the public, if all goes according to plan, in ten to twenty years, most folks will have forgotten that things can be any different, and the lucky few that influence media and public discourse will probably have it even better than they do now.

      • Deceased MD

        It’s hard to believe that they can keep this up. After all Rome fell.

    • SherryH

      “Most won’t accept any tests from other facilities”…what a flagrant waste of money. Redundant and unnecessary, and completely unfair to the person/persons who are paying. One more reason health care costs more than it should.
      Is it all about money? Does anybody care about the patients?

      • Patient Kit

        Unfortunately, yes, except for patients and doctors, I think Big Health in the US is a big business — one of our very biggest businesses — that is, first and foremost all about money. That’s what happens when we let profit driven entities (insurance cos, Pharma, hospital corps, etc) run the show.

      • Deceased MD

        Sheryl, I am so with you on this.. But I think there is some truth that there is a conflict of interest for many docs that work within the Corp Med. world. And in these big systems, I think patients are often shortchanged and can be overlooked/overcharged etc.. And unfortunately private practices are struggling and can’t compete with the big hospitals even though they can do the very same thing for a fraction of the cost. What drives up prices for example is large hospitals are allowed to charge a facility fee to pts and insurance often pays for it. Medicare allows for it. How crazy is that? Basically they are asking the patient to pay for rent to use the out pt facility office in the medical building associated with the hospital. I would never have the nerve to charge patient’s for my office rent and of course rightfully so insurance would not cover that as it is ludicrous. But insurance pays for it when it is an outpt doc in a hospital. So pt’s are charged for the doctor visit PLUS the facility fee.

  • Dr. Drake Ramoray

    The problems isn’t th EMR specifically. Technology is great. The problem is mandates and meaningful use. I only wish I had he freedom to run my practice like Katz deli.

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

      You can have it…. :-)

      • Dr. Drake Ramoray

        As you know I’m working to that end. :). Assuming that it doesn’t become mandated that I see Medicare/Medicaid to keep my medical license.

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

          I know there is talk about those mandates, but it will never happen because the last thing the 1% wants, is to share their posh doctors with Medicare and Medicaid “beneficiaries”.

  • Patient Kit

    Great. I was going to have a nice healthy Greek salad for lunch. And now I have this powerful craving for pastrami. >:-(

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

      Oops…. sorry about that, but unless you live in New York, no need to bother…. :-)

      • Patient Kit

        I do live in NYC (Brooklyn). At this very moment, I’m just across the river in Brooklyn, a handful of subway stops from Houston St. At one point in my life, I lived on E. 1st St in the East Village. I don’t have time to go to Katz’s today. But you have planted the seed! I’m munching on a salad right now before hitting the pool at my Y for some laps. But I sense some pastrami in my near future. If that was the main intention of your post (!), mission accomplished. ;-)

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

    I think they’ll get a taste of it now that Medicare released its “troves” of data showing how doctors “reap” millions from our weak and defenseless government. A handful of known (and currently under investigation) common criminals are now painting the entire medical profession (working on a blog post as you can tell…:-)

  • ninguem

    “What health care can learn from Katz’s Delicatessen”

    I know, I know……

    waving hand like Arnold Horshack

    that…….I’m in the wrong business.

    http://37.media.tumblr.com/tumblr_m8r80eK1I21qcw9y0o1_400.jpg

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

      after learning from cheesecake, airplanes, banks, race cars, just cars, Starbucks, McDonald’s, Walmart, agriculture, plumbers and what have you…. let’s do cold cuts 101….

  • Deceased MD

    This is the kind of junk I am getting from insurance comparing “average risk” of pts seen in different practices. Anyone else dealing with this?

    “Risk adjustment is a component of the Patient Protection and Affordable Care Act (PPACA) that is dependent on reporting accurate
    clinical information. According to PPACA, health plan carriers are required to provide diagnostic information to the Centers for
    Medicare & Medicaid Services (CMS) for all customers who enroll in their individual and family plan business through the Public Health
    Insurance Marketplace. The CMS then reviews the diagnostic information and determines the plan?s average risk. The average risk
    score is compared against that of other health plans participating in the same states and markets. If there are any health plan carriers
    with a disproportionately higher risk score, CMS requires that those carriers with lesser risk compensate the ones with higher risk.”

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

      What do they want you to do?

      • Deceased MD

        I take it as a warning of sorts of things to come. That you can’t be spending too much time with anyone who is not “high risk” etc.

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

          Looks to me more like reminding you to slap all possible Dx on patients’ claims so they look high risk enough to not cause the plan to be penalized….

          • Dr. Drake Ramoray

            There is more truth To this than you may realize. Take a relatively simple well controlled type II diabetic on insulin with mild retinopathy. Most docs code this 250.00

            If you code 250.50 (diabetes well controlled with ocular complications), 362.01 (diabetic retinopathy), and V58.67 (long term use of insulin) then yes the patient looks more complicated (or is coded correctly depending on your point of view).

            This could be done just because its the correct way to code, could be done to justify a higher charge, or could be done to allow one’s corp med masters to allow the doc for more time with the patient (or all of the above).

            One of the internists in a corp med practice I left used to always love to code 412.xx. (Old MI). He would use it for stress tests on just about anyone he could get away with it.

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

            Oh yeah… the manifestation codes and the old MI… classic HCC strategy. Medicare Advantage makes a killing off these things….

  • SherryH

    On a lighter note, the Apple Store could learn some lessons from any successful deli!

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

    I don’t think it does end…
    Here is the “funny” thing about facility fees: the hospitals argue that maintaining state of the art facilities costs them more and Medicare should acknowledge this and pay accordingly.
    The other side of the mouth argues that doctors should all be employees of these big systems because they can provide “economies of scale” that small mom & pop shops cannot. I guess their definition of “economies of scale” is the exact opposite of what most people think it is…. :-)

  • Deceased MD

    I am glad you know about this. Sometimes I feel like I am on another planet. There is so much that is corrupt and the ACA has really done nothing to address the corruption. Do you know about the fact that Medicare cannot negotiate with big Pharma on drug costs. Whatever they charge is what medicare pays. Asthma drugs and gout drugs that were generic 10 years ago have now been repatented and cost like 10X more than previous. All basic generic drug that are now unaffordable. Really there needs to be laws to protect the patient or now referred to as the consumer. but there are too many lobbyists and too much corruption for change. Sorry to rant but I find it offensive and I am delighted you know about much of this. Most people don’t.

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