A Country Doctor Writes:

I pay $500 per year for UpToDate, the online reference that helps me stay current on diagnostic criteria and best treatment options for most diseases I might run into in my practice. They also have a rich library of patient information, which I often print out during office visits.

I don’t get any “credit” for doing that, but I do if I print the, often paltry, patient handouts built into my EMR. That was how the rules governing meaningful use of subsidized computer technology for medical offices were written.

If I describe in great detail in my office note how I motivated a patient to quit smoking but forgot to also check the box that smoking cessation education was provided, I look like a negligent doctor. My expensive EMR can’t extract that information from the text. Google, from my mobile device, can translate between languages and manages to send me ads based on words in my web searches.

When I do a diabetic foot exam, it doesn’t count for my quality metrics if I freetext it; I must use the right boxes. If I do it diligently on my iPad in eClinicalWorks, one of my EMRs, even if I use the clickboxes, it doesn’t carry over to the flowsheet or my report card.

Not only are these things annoying and part of the mounting overall frustrations of being a doctor, or PA/Nurse Practitioner, today. They are also misguided; I may document a foot exam or provide a disease specific handout, but then what?

Our primitive technology can’t automatically do anything more. Did the printed information change my patient’s behavior? Did the foot exam reveal diabetic complications, and did I do anything about that? Did my smoking cessation advice (CPT code 99406) produce results? Or did the patient quit on her own because her sister got lung cancer?

More and more, I am thinking we, as providers, are measured too much for the wrong things.

I also think that, more and more, we are expected to do the wrong things.

My diabetic patient may see a well qualified podiatrist, who spends a great deal of time examining and treating my patient’s feet, but I am the only one who can prescribe the diabetic shoes. How detailed does my foot exam have to be for that prescription to count? Not very, mostly clicking the designated box.

I don’t double check the retina specialist’s work examining and injecting my diabetic patient’s eyes, now, do I? I am only charged with documenting that my diabetic patient sees the eye doctor. I wonder why Medicare needs me to tell hem that when they are presumably paying big money for that to happen?

In our fifteen minute world, wouldn’t it be better if I had time to read the podiatrist and eye doctor reports and use them to help motivate my patient to eat differently and exercise more? Instead of:

Have you seen the eye doctor? Check.

Have you seen the podiatrist? Good, let me check your feet real quick so I can say I did it and get you the shoes he wanted you to have…Check.

And do you know smoking is bad for you? Check.

Do you know too many carb calories raise blood sugars and cause weight gain? Check.

You don’t drink too much, do you? Check.

Not too depressed this time of year? Check.

Did you get your flu shot, colonoscopy and Pap smear? Check.

And what about hepatitis C, domestic violence and making out those Advance Directives? Check.

Makes me feel I’m a great doctor. Or does it?

There is another dimension of Medicine, invisible to those who measure us, but it is the only one our patients see.

Last week I had a patient with mild kidney disease and a high potassium. I thought that would be easy to take care of. We called around to all the pharmacies from Bangor to Ellsworth to Belfast and nobody had Kayexalate, the time-tested antidote, in stock.

It happened to be on a Tuesday night with my Suboxone group starting at 5 o’clock. The patient had been there since 4, his labs were available by 4:30.

It was 4:45 and we were almost done calling around to pharmacies. I had Autumn, my medical assistant, make some of the calls. 15 minutes left before clinic with 14 patients to see in 90 minutes (we pull them out from group therapy to check in and renew their scripts). And I had a new patient, an internal transfer but still new to me, with multiple medical problems to see before clinic.

I did what I hardly ever do: I asked Autumn to call the emergency room on my behalf and tell them that we had no choice but to send the patient over. We faxed records and lab reports and I moved on.

The ER doctor’s report was scathing. He clearly thought I had dumped on him. He didn’t do what I had thought he might do:

I hadn’t done it since I stopped doing hospital medicine a generation ago but I know you could hydrate him to help his mild acute kidney injury and coadminister glucose and insulin to lower the potassium at the same time.

Instead, the emergency room doctor gave him Kayexalate, because the hospital had it in stock. He probably didn’t know that wasn’t an option for us. I looked like an idiot to him, but that often happens in primary care.

I had gotten over my frustration and embarrassment when, this week, I had a patient on warfarin with a supratherapeutic INR and no active bleeding. I’ve never been terribly nervous about those situations but this was a high number and Up-To-Date suggested vitamin K, orally because it works faster than injectable, while obviously holding the warfarin. So, guess what, we called every pharmacy from Bangor to Ellsworth to Belfast and nobody had vitamin K in stock. The Natural Living Center in Bangor had a very low potency supplement where maybe 50 pills would be enough of a dose to make a difference.

Oune of the hospital pharmacists was available to talk to me and explained that a small bottle of vitamin K in the potency required to reverse warfarin costs about $1,000 and neither hospitals nor pharmacies want to stock them because they will lose so much money if the drug expires. What the hospitals do instead is compound an oral form from the injectable that is still expensive but less so. But a hospital can’t sell or administer to an outpatient whose primary care physician does not have privileges at that hospital. I technically have privileges at Cary Medical Center in Caribou, but that’s 200 miles north.

So this was a judgment call: Send the patient to the emergency room so she can incur the emergency room fee and have them give her an oral medication that may or may not make a difference since she had no active bleeding. Or I could bubble wrap her for a couple of days while the warfarin effect wore off.

Today, in Van Buren, I called the small local Rexall (a historical U.S. pharmacy name) and chatted with the owner, John Hebert. He has Kayexalate in stock. This is in a town of 2,000 people. From Bangor to Ellsworth to Belfast I imagine there are 100,000 people. They don’t have outpatient access to this drug.

It’s a sad situation when potentially life-saving medications are unavailable because pharmacies don’t want to risk having them expire and go on unsold. We have automatic defibrillators in schools and shopping malls, why not some basic antidotes available, maybe even subsidized, in strategically located pharmacies?

P.S. Hebert’s is about to open a pharmacy in Bangor within the next few weeks and John has promised to stock Kayexalate there, too. And he delivers to a large geographic area…

The young woman was only slightly overweight, with a BMI of 28, but she seemed really wound up about her need for me to continue the phentermine her previous doctor out of state had started her on. She volunteered that her BMI was only 29 when she started.

She was a walk-in patient, not a regular, and we didn’t have any records on her, except I was able to verify her prescriptions on the multi-state Prescription Monitoring Program website. I told her it was incredibly easy to lose weight if you really want to, “just don’t eat any refined carbs”, and cited my own example as a recovering vegetarian.

She almost broke into tears.

“With your weight, you don’t even have to be all that radical to get your BMI down under 25”, I tried to reassure her. She did not seem reassured.

I decided to try some analogies.

“Taking diet pills with a BMI of 28 or 29 is like asking for ADHD medication just so you can stay up all night and study for a final exam; it’s not a case of a lifelong, debilitating problem.”

She burst into tears.

“They do help me keep track of my life, I’m so disorganized and so distracted. I flunked out of college, I can’t keep a job…”

“So you think you have ADHD?”

“Yes, and PTSD and anxiety.”

“Well, then, let’s deal with that! I’ve got Behavioral Health Staff right here. On Saturdays, too.”

She stopped crying. I looked at the clinic schedule. My psychologist had a no-show.

“I can introduce you to my psychologist, who can help figure out your diagnosis. Would you like to meet him?

“Sure”, she said and straightened up in her chair.

“You wait right here and I’ll be back in a few minutes.”

I made the introduction, mentioned that I have collaborated with Dr. Brandt for 25 years, and said:

“I’ll refill the phentermine for one month only, and you guys figure out what’s the real problem with your attention. Then, when you see your new primary care provider, you’ll be able to go over what you and Dr. Brandt have found out and go from there. Deal?”

“Deal”, she said, and added “Thank you. I was almost ready to walk out.”

“Just be straight with us. We’ll work with you”, I said and excused myself.

There were three more walk-ins waiting to be seen.

I love my job. And I love working in an integrated practice.

I have many equally important administrative and clinical duties, but I miss many more meetings than patient appointments. The reason for this is simple: Non-clinical activities are scheduled by non-clinical people in Microsoft Outlook and patient appointments are scheduled in our EMR.

No-showing for a patient appointment is extremely bad patient care, and I go where the EMR tells me to go.

Outlook can send instantaneous, simultaneous invites to hoards of people, who with one screen tap or click can accept and populate their schedules years in advance.

The EMR requires specially trained and authorized people to custom create blocks of various types which may show up in one (grid) view but not in another (list) view.

This is a small, but telling example of how an activity that even the most basically computer literate person handles automatically in the business world requires special skill and privileges in a modern EMR.

Non-clinical coworkers are still puzzled by my seemingly erratic meeting attendance, and they give me blank stares when I suggest they stop using Outlook and make the EMR their appointment book and message hub. They’re no fools; they know how clunky my technology is.

And (I’m on a roll now), compare EMR messages with email: If a clinical message in my EMR has various new timestamps and comments added to it, it doesn’t move to the top the way emails do; it stays in the order it was created, so while I never miss a patient appointment, I do miss new information in patient communications.

Why does my EMR not work like modern office computer programs? It’s a rhetorical question we all know the answer to: Proprietary functionalities of their software with lack of interoperability is a cornerstone of the business strategy of EMR vendors; profits to be made as long as customers stay with the product. And the more expensive and complex it would be to migrate data and retrain people, the surer those ongoing profits are.