Sharing administrative pain might give us more joy in medicine


I’m still trying to figure out what happened. I don’t want to be put on suicide watch by the wellness office. It definitely began during our weekly noontime mindfulness session. I came in late, furtively signed in (gotta make that metric) and slipped into a back corner seat. I went zero to REM in 10 seconds, thanks to last night’s click-boarding my panel into their patient-centered medical i-homes.

I awoke to hear another meeting going on. I could hear our administrators. They sounded unhappy and frightened. I thought, “Layoffs? ‘Would Recommend’ numbers down?” Cracking an eye open, I could see them surrounding Mindy, our practice manager, offering advice: “Click that box. No, down there.” “It won’t go through because you have to pick who gets CC’d,” “You can’t click out until you have done the Met Rec.” “Make sure you log this as a 199205, high-complexity.” “No, there was little administrative risk. Compliance will flunk us.”

My double-bookings and probationary “Wait Time” numbers overruled my curiosity, briefly. But I just had to find out what was going on. When my last patient canceled, I stopped by Mindy’s office without pausing to rue the lost 2.11 RVUs. I asked, “What’s going on? What were those acronyms?” Pointing at the screen, she signed, “It’s the rollout of this new administrative electronic record. They call it the AER. I call it a huge waste of time.”

Mindy appeared traumatized, so I guided her back to my office and opened a session in Saga. Mindy began, “Our meetings have kept expanding, but we don’t have enough conference rooms. A consultant crunched our numbers and told the VPs that we had enough rooms. Our problem was inefficient usage. They did their due diligence, found the low-hanging fruit and recommended leveraging Saga, our EHR system. Saga has a module for an AER, an administrative electronic record.”

Mindy went on, “It’s pronounced ‘air,’ to evoke visions of frictionless data gently wafting into the cloud. It is anything but airy — more like a hand crank Model T. Our finance people scold us that the AER is “best of breed.” It allows senior leadership to track our productivity, benchmark with peers and ensure compliance.

As for the terminology, the consultants told us that most were crosswalked from the clinical version of Saga. Met Rec is metric reconciliation, the system’s attempt to rein in the operational and quality dashboards spawning metrics galore. To get us all on the same page in terms of targets, we have to do Met Rec at the beginning and end of every meeting.”

Then Mindy inhaled, and warned, “I’m taking you on a deep dive. In every meeting, each policy that we discuss must now be logged in ICP-10 nomenclature, per the 10th International Classification of Policies. Our compliance people say that we should be managing three to five ICP-10 codes at each meeting; not to worry, there are tens of thousands to choose from. The CAT codes that we were debating are modeled on your CPT office visit codes 1-5. Each Current Administrative Terminology code generates an AVU, or administrative value unit, to capture the different administrative intensities entailed in counseling a senior clinician about her clinic inefficiencies (4 AVUs) or orienting a newly graduated physician to Saga (2 AVUs).”

Mindy kept typing on her laptop and didn’t notice my eyes glazing over. She continued, “We also need time each hour to finish the EOM, or end of meeting, the module that you heard us slogging through. I keep hearing the consultants’ mantra in my sleep, ‘If it isn’t documented, it wasn’t done.’ Then we distribute the documentation to attendees and referring administrators. The notes are mainly copy/cut/paste; there isn’t enough time to make a decent note and get the meeting done. People across town tried scribes, but they got sloppy in their pajama proofreading. Someone approved a career-ending diet joke about the CEO.

“The final hassle was the new hard stop for Meeting Order Entry or MOE. Pronounced mow-ee, like POE. We have to order everything electronically in the AER, even simply booking the next meeting. If Tony my assistant tells me one more time, ‘Can you put that in the AER?’ I’m gonna put him six feet under. But I know it’s not his fault.”

Mindy slammed her fist down. I didn’t dare interrupt. “The consultants keep telling us the same thing that those kids from the software vendor said: ‘It’s a state-of-the-art system. If you do your training, and you create all your macros, you’ll be fine. If you have any suggestions for the next upgrade, let us know.’“

Mindy’s face contorted with pain and disbelief. She said, “Who has said ‘macros’ since the 1990s? And no one submits comments. Suggestions get you ’Stop complaining. Do more training.’” Mindy wasn’t done. “Worst of all, our long meetings that encroach on your conferences will affect our metrics. We administrators are now graded monthly by a phone survey of patients and you clinicians. Next month, as part of ‘transparency,’ they are going to post our scores on the web. We are going to get bottom-box scores on wait time, and administrator explained. Where’s the metric for my hour on the phone this morning getting your lady from the North End a write-off on her bill?”

Since my administrative role in this encounter was listening (CAT 199205) rather than intervention (CAT 161250), I didn’t admit to Mindy that I always hang up on those robocalls, just like my patients do. Mindy had always been accommodating in ‘splaining new mandates. I would have rated her highly, but I value my dinner more. I clicked Mindy out, arranging an urgent referral for anger management, including resilience coaching, more AER optimization, and yoga sessions. To convey the urgency, I documented the referral diagnosis as “Homicidal administrative tantrum episode, initial encounter, no visible weapon” or .hate1 in my macros, AD911 in ICP-10. I also consulted Dr. Google and learned that Saga’s EHR and AER comprise the next wave of enterprise-wide systems, dubbed the Physician and Administrator Integrated Network, or PAIN.

The next thing I remember is finding myself in that corner of the conference room. As a senior clinician with marginal metrics, I couldn’t ask anyone if this was a dream; they’d send me for a behavioral health e-consult. Mindfully reflecting on my drive home, resiliently bracing for the evening’s pillow taps, it occurred to me that spreading PAIN could align incentives to reduce mindless clicks across the continuum of care. It may be too much to hope, but shared PAIN might give us some joy back to medicine.

Walter J. O’Donnell is a pulmonary physician.

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