DIY

by Rob on May 12, 2013 · 5 comments

in EMR, My New Practice

Hole in the Wall

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.

router_bits

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!

Hole covered

Yes, there still is a minor wallpaper issue, but note the total absence of gouges!

Roundover

Also note this fine example of the roundover cut.

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.

There are several reasons I’ve avoided doing this DIY project:

  1. If I fail, I’ve wasted a bunch of time I should have been building my practice.
  2. If I succeed, I don’t just have a practice to manage, but a piece of software.
  3. I tend to get obsessed with details, losing hours coming up with elegant solutions to problems for which simple solutions are available.
  4. It requires that I spend far too much time thinking about HIPAA and security issues.  I hate that kind of thing.  It bores the socks off of me.  I fell asleep three times while writing this bullet point (and I have no socks).

Business is good; we are up to 250 patients and are managing the volume pretty well.  But I’ve had to keep a cap on growth while I figured out what system I would use to run the practice. Obviously, EMR systems designed to produce enough E/M vomit to scare away Medicare auditors don’t fit with my business plan. Other systems seem to have become so obsessed with “meaningful use” that they don’t do basic business functions.  Expecting a system designed to work with the Economics Through the Looking Glass of American healthcare to function in the real world is folly, and so I had to choose: do I stay with my current non-system and let the quality of my care suffer, do I keep growth of the practice to a minimum, ignoring the reality of 3 kids in college next fall, or do I give in to the belief that I know what I need and can build a computer system that will work with my type of practice?

I decided on what’s behind curtain number 3.  Unfortunately, this all happened just as I agreed to an interview with a local TV station – an interview that went viral and now has people as far away as Idaho and San Francisco wondering if they can be my patients.  Now the pressure is really on to make this thing work.  I can no longer be indecisive; I will either live by the database or die by it.

So far, it’s been going well.  Despite a few “unfortunate” moments where I deleted all records of everything (thank goodness for paranoia about backups), I have broken the code of working with a relational database, and my nature as an internal medicine problem-solving nerd has served me well.  In truth, this is not much different from what I did with the EMR system at the old practice.

  • I think about where the greatest pain is for me and my nurse, and fix those problems.  Where can time be saved, and jobs be made simpler?
  • I think about where the greatest risks for patients are, and fix those problems.  What things are easily forgotten or missed?  How can I set the system up so it assures the safety of my patients?
  • I think about where I want to go with the practice in the long run, and set up a system that will set us up to go in those directions when we are ready.
  • I think about the questions I ask myself when dealing with a patient, the information I want to know the most, and put that information in a place where it’s easily accessed.

In reality, the software borrows heavily from software real businesses use:

  • Contact Relations Management to keep track of interactions with customers (patients)
  • Business financial management to keep track of costs and of who has paid (and who hasn’t)
  • Document management to handle the reams of information flung at me on a daily basis.
  • Task management to keep important tasks in front of me and my nurse (and eventually patients)
  • Spreadsheets to organize numbers
  • Reminders to tell when important things are due
  • Communications systems both between office staff and with patients

It’s really a hybrid of all of these, with the additional plan to securely share much of the data with my patients online.  My hope is to build something good enough to get the interest of someone who actually knows what they are doing in writing software.  I know what problems need to be solved, and am learning much about how a good database program can do that (I am using Filemaker Pro because it’s cheap, it’s easy, and it works on both Macs and Windows), but I know my limitations.

I still have no desire to become a software tycoon.  I am doing this only because it’s the only way I could see to make this practice work.  The practice is still at the center of my motivation.  If it doesn’t help me serve my patients better, I won’t do it.  The amazing thing is that we used it all of last week and my nurse didn’t quit.  That’s a good start, but the real test comes this week, as we take on the barrage of new patients brought on by our recent publicity.

I’ll keep you posted.

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This material, written by me, is free to re-post and share under the Creative Commons agreement. In other words, use it all you want; just give me credit.

More Trouble

by Rob on May 5, 2013 · 8 comments

in American Medicine, Health Care, Health Care - How it's Broken

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.

oliver_p&b

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.

cardassian-kardashian

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! ”

They aren’t, of course, and we are paying the price for “more.”  This hunger for “more” is fueled by the media’s fascination for the “latest thing,” the long disproved idea that technology will solve everything, and docs who aren’t willing to take time to explain why it’s actually better to do less.  It’s hard to do, when we are paid more to spend less time with patients, and when the system is willing to pay for more and more.

There is a voice against this: the “Choosing Wisely” campaign, which argues against unnecessary treatments and tests.  This is a welcome voice of reason in the cacophony of cries for “more.”  Yet the battle goes against the irresistible tide of our payment system.  The root problem is this: there are a whole lot of people whose jobs depend on America’s addiction to “more.”  The payment system has created an ecosystem that thrives off of waste (of which I once wrote an allegorical fantasy).  True health care reform will be catastrophic to many who work in health care, with many very nice and hard-working Americans losing their jobs at the ACO factory, at Meaningful Use Inc., and even at Stents-R-Us hospital here in my home town.

This is what you get when you make disease more profitable than health, when we treat problems instead of people.  The simple fact that our system would be destroyed if everyone got healthy should tell us something is terribly wrong.  Doctors want their offices full, not empty.  The goal of every patient – to be healthy and to stay away from the doctor – goes directly against the economics of “more.”

I have always tried to be a non-test orderer.  I was trained well by docs who believed it weak-minded and bad care to blithely order tests and prescribe medications without a well-defined reason.  This has always made it harder for me, as it’s far more time-consuming to explain why a drug or test is not needed than to simply order it.  But in my new world, one in which an empty office is a good thing, I’ve found my patients much more open to my aversion to “more.”  The main reason for this is that I am giving them more of me.  More of me means they can call if they don’t get better, or if their symptoms develop.  They know I won’t force them to take more of their time and spend more of their money to get my attention.

Ultimately, I want my patients to see as few doctors, be sick as infrequently, and be on as few drugs as possible.  I hope to wage an all-out assault on “more.”

Here are my rules to battle “more”

  1. Never order a test that doesn’t help you decide something important.  Ordering tests “just to know” does much more harm than good.
  2. Use consultants only to do things you can’t.  Orthopedists will aways give an NSAID and physical therapy for problems, so I don’t send patients to them unless they’ve failed those treatments (where appropriate).  I am just as good at ordering PT, and am more careful with NSAID prescriptions than they are.
  3. Don’t give a patient a drug without explaining to them why they need it.  If I can’t make a good case for a drug, I shouldn’t be giving it.  This is not simply “to lower your cholesterol,” or “to treat your blood pressure,” but because doing so will raise your life-expectency.
  4. Remember the number that really matters: how many birthdays a person gets to celebrate in health. I don’t care about blood pressure, LDL, or even A1c if treating it doesn’t raise the birthday total.
  5. Don’t forget about another number: how much money patients have in their wallets.  There’s no point in ordering a drug they can’t afford, or making them pay for a test they don’t need (even when they ask for either).

I hope my new world of less overhead, less regulation, and less antacids for me continues on this trend toward less sick patients, less drugs, and less tests.  Perhaps I need to break into a song and dance number whenever my patients ask for “more.”

That would teach them.

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This material, written by me, is free to re-post and share under the Creative Commons agreement. In other words, use it all you want; just give me credit.

Telling a Good Story

April 28, 2013 Health Care - How it's Broken

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 [...]

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Collaborators

April 6, 2013 Collaborative Records

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: [...]

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Waiting for Theoden

April 2, 2013 My New Practice

It’s official.  The road sign clearly welcomed me here.  I guess all business start-ups have to go through this town. What?  No bravado?  No chest pounding about how my ideas will change health care while making patients smell as springtime fresh?  Nope.  None of that.  It’s hard to get excited about ideas when only money [...]

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Say it Ain’t So, HIPAA!

March 25, 2013 Health Care - How it's Broken

Dear HIPAA: I’m sure you get a lot of hate mail, especially from folks in my profession, so when you got this letter from me you probably assumed it was more of the same.  Let me reassure you: I am not one of those docs.  I do think patient privacy is important, and actually found [...]

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Getting Engaged

March 11, 2013 EMR

“Patient engagement.” What is “Patient Engagement?”  It sounds like a season of “The Bachelor” where a doctor dates hot patients.  It wouldn’t surprise me if it was. After all, patient engagement is hot; it’s the new buzz phrase for health wonks.  There was a even an entire day at the recent HIMSS conference dedicated to [...]

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Trickle Up Economics

March 5, 2013 Health Care

It’s been a month since I started my new practice.  We are up to nearly 150 patients now, and aside from the cost to renovate my building, our revenue has already surpassed our spending.  The reason this is possible is that a cash-pay practice in which 100% of income is paid up front has an [...]

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For the Record

February 26, 2013 EMR

For the record: I am a geek.  I love technology.  I adopted EMR when all the cool kids were using paper.  Instead of loitering in the “in” doctors lounge making eyes at the nurses, I was writing clinical content and making my care more efficient.  I was getting “meaningful use” out of my EMR even when [...]

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Death of an Evangelist

February 24, 2013 EMR

It feels like part of me is dying.  I am losing something that has been a part of me for nearly 20 years. I bought in to the idea of electronic records in the early 90′s and was enthusiastic enough to implement in my practice in 1996.  My initial motivation was selfish: I am not [...]

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