We have a problem in our clinic.
Between our EMR implementation a few years ago and our PCMH recognition shortly after that, our office visit documentation has become bloated and our cycle time has almost doubled.
There are no brief visits anymore, since every visit entails screening for multiple psychosocial conditions and consideration of various immunization and health maintenance reminders.
Nobody sees over thirty patients a day anymore; we’re lucky to exceed twenty.
That means patients today are actually more likely to go to walk-in clinics or emergency rooms than they were a few decades ago. We’re still okay with PCMH as long as we have a single open access slot at the beginning of every day, and we don’t actually get any credit for squeezing in, or double booking, acutes.
It also means patients with chronic illnesses get seen a little less often than they used to. Sure, we have RN case managers who can stay in touch with them, but the communication between them and the medical providers is hampered by the new busyness of checking our electronic inboxes, which takes seconds longer for each item than the old paper reports used to take, and which is done “in between patients” in our already tight schedules or after hours, staying late at the clinic or logging in from home.
It wasn’t supposed to be this way.
Here is what we hoped and were led to believe would happen:
1) EMRs were supposed to make documentation lightning fast.
2) EMRs were supposed to make data review and retrieval faster than paper systems.
3) PCMH would have us transform into physician driven, super-efficient, yet warm-and-fuzzy places filled with patient friendly personal touches.
Instead, medical practices have evolved into bigger bureaucracies with OCD afflicted doctors who don’t lead practice transformation, but who feel personally responsible to compensate for all the shortcomings of their hastily implemented, immature technology.
OCD may be the most significant and destructive acronym in today’s healthcare environment. And we have all been cultivating it, medical practices and providers alike.
The old school expression of OCD, in Marcus Welby’s era, was extremely high physician productivity and unwavering personal commitment to patients.
The new manifestation of OCD is trying to follow overly ambitious, often conflicting Federal edicts and mind-melding ourselves with our computers to the point of losing touch with our patients’ real needs.
Why else did we end up with a working environment where we allow ourselves to be distracted by health maintenance discussions when somebody comes into see us for what should be a ten minute visit for a simple sore throat, or when they are in pain from an injury?
(A ten minute oil change for your car is not the same as a 100,000 mile service, is it? Why is health care any different?)
Why else do we think that it is appropriate to do depression, alcohol, smoking, domestic and drug abuse screenings on new patients the minute they walk through the door to size us up as their chosen new health care provider?
(How did it become patient centered not to spend the first visit, or even the first few minutes of a new therapeutic relationship, listening to the concerns of a new patient?)
Why else, if not because of our personal and organizational OCD, are we sending our own patients to the walk-in clinic instead of fitting them into our own schedules? Isn’t it because of our obsessive fear that we might document such a quick visit without the required Federal accoutrements and end up scoring poorly on some arbitrary quality scale?
(Do we really think the walk-in clinic will do a better medication reconciliation than we do if we squeeze a 45 year old hypertensive diabetic in for quick look at an ankle sprain?)
Pardon my comparison to veterinary medicine, but in my veterinarian’s cash practice, they manage their health maintenance reminders by simply printing them automatically on the receipt. If I bring a pet in for something simple, they don’t bloat the visit up by talking about things I didn’t come in for; they stay on schedule and I can read the printed reminders at my leisure.
Somehow, in the new vision of primary care, we went from taking care of our patients over a continuum of time to doing everything all at once, as if there were never going to be other visits. That kind of OCD is anathema to real primary care.
And somewhere along the path to more patient-centeredness, we got sidetracked by the paternalistic ambitions of our biggest payer, Medicare, into hammering our customers with Federally imposed public health agendas that have little to do which their personal vision of why they need a doctor.
To quote a new patient who came in to size me up a few years ago:
“I need a doctor when I’m sick.”
Access, in other words.
A Country Doctor Writes: 
A solution in three simple words…Direct Primary Care.
Thank you for the writing you do…when I’m fed up with the care on the patient end, you are a righting-of-the-world view from the physician end. Appreciating that a lot.
I’ve been a bit snarky at times and told intake that I don’t want to answer those questions. I’ve told them that if I fall, i’d tell them all about it, and I mean all.
I was diagnosed with hypothyriod in the 1980s. My last 5 doctors didn’t know how to reduce thyroid dosage when my labs say that the TSH value is too high. Now I have a good Saudi doctor. She didn’t know anything about thyriod, but she knows how to effectively use her electronic pad.
I had to go to UC to get an order for a thyriod screen. My PCP is on maternity leave. It’s almost time to get my annual TSH, and I started having symptoms of my THS levels bouncing-I grew up in hot uraniium country and endoctrologists blame that for the bouncing. Anyway, I’ve been treated poorly about thyroid, and I get anxious-scared of doctors. I don’t know why I don’t have a heart condition or stroke from this 190-220/110+. I still have scars from a BP med fall.
I recenly had eye problems, boils, fatigue, dry skin, weight changes, dry skin, muscles hurt so much, -on and on.
I refused an appointment unless I could have a THS for sure. I managed to get it that printed, and they told me to go to UC. I took it to UC 2 weeks ago and apologised, and showed them the print out. They weighed me, looked at the boils-prescribed a topical antibio for that. Read the note from PC, and ordered a TSH. It’s in range and that greatly reduces my anxiety.
My eye doctor was able to diagnose my eye problems without the extra work involved with possible thyriod issues. I’m the first to admit my anxiety levels went down, and I feel better. It helps the eye pain is almost gone, etc.
All of the Mickey Mouse regulations cause physicians and patients to lose out in another way, the physicians are so harried that they can’t communicate about things -like hypothyriodism- reduce the dosage somewhat. I am not hinting about any clues from you. The doctors in my advantage plan need to earn their money-maybe learn something.
I appreciate your excellent insight and how you speak up.
Thank you
Have followed your blog with interest. I am a 61 year old family physician in small town Louisiana. I am a huge supporter of digital health information and have written my own digital chart system – it actually works and its free.
CMS sponsored EHR are designed by IT, for IT and supports large corporate systems of decentralized care where accounting and metrics are all that matters.
Joint the movement now – start using digital health information intelligently and quit using CMS/IT sponsored EHR terrorism
There, that feels better
One of the best blog posts: “To quote a new patient who came in to size me up a few years ago:
“I need a doctor when I’m sick.”
Access, in other words.”
I’ll remember that one. 🙂
“We have a problem in our clinic”
Yes, you do – you seem to buy into every half-baked idea that comes down the pike. Why not stand up for yourself and your patients – ditch the EMR, forget PCMH, and just practice medicine?
Or do you just like complaining?