A Tale of Two Centricities

In my old practice, I had an Electronic Medical Record system (EMR). The paperless office: all patient data entered in real-time into computers, all documents scanned, even digital photos transferred directly into the record. No more searching for lost charts, no more waiting for the front desk to hand the chart to the nurse who then hands it to me (who hands it back to the nurse, who then hands it back to me, who then returns it to the front desk); no more trying to decipher doctor's chicken-scratch handwriting; instant access to every patient's record from any computer with an Internet connection; and most importantly, near-complete recovery of every single patient record after the most devastating disaster in recent history.

That EMR was provided by a company called eClinicalWorks. They're a good little company with a good, nimble, customizable little product. It's far from perfect, but it did the job really well, and very affordably. I think of eClinicalWorks as a butterfly: small, delicate, and beautiful.

The practice I am now in uses a different EMR, called Centricity, from GE. Yes, that GE (you'd be surprised to learn how much GE is involved in health care). If eClincalWorks is a butterfly, Centricity is a hippopotamus. Big, lumbering, powerful, and utterly without grace. It's not going to listen to you unless it wants to.
I actually don't have much complaint against Centricity. Like eCW, it also does the job. It does many things eClinicalWorks never could (such as scale up to a massively multi-user, multi-site organization, the opposite of the solo private practice; also robust user-tracking, recording who entered and changed what in the record); I bet--though I haven't yet had the chance to find out--that it is much better at data collection and analysis. It's been fairly easy to learn and use, and hasn't significantly slowed down my work, or interfered with patient interaction.

But it does have some major drawbacks. Only one person can work on a record at a time, lest you risk crashing the program. The printed output leaves something to be desired. Small program changes have to be referred to the clinical committee, which then refers changes to the organization's IT department, who then sometimes has to work with GE's programmers.
Most interesting of all, the program's biggest strength is in collecting and recording patient background data: what language they speak, how they prefer to learn new information, if they have cultural concerns, etc. Combine that with its privacy features and user-tracking, and it seems that it was created with HIPAA and regulations first.

Privacy and compliance is important, yes. But I'm more than a little concerned that this product seems to have placed that area as most important--and physician input, management of assessment, plans, medications, immunizations, and such becomes second tier. I imagine a different Centricity, created first and foremost as an Electronic Medical Record: patient data, ease of entering and retrieving it, being the priority. Lay the compliance onto this template, add a pretty interface, and *boom*--you've got a revolutionary new product. However, that's not the Centricity that GE decided to create.
(It's all the more frustrating that this big expensive product was created by a big powerful company like GE. You'd think that GE would have the resources and insight to do it better. Of course, that might be part of the problem right there: hey, we at GE don't have to listen to those doctors or medical practices; we're smart enough to do it ourselves, with what we think is important. If you don't like it, that's tough, because we're big ol' GE, and we know best.)

And so we're still waiting for that hypothetical ideal EMR that satisfies all parties and concerns.

Yes, here in 2007 we still have a long way to go. (Though, did I mention that we're using the 2004 version of Centricity? There's an update, but it's still in beta. Our organization has, quite wisely, decided not to trust its patient data to an unfinished product.)

And some people wonder why doctors have been slow to switch to EMRs.

Your Insurance Sucks

A mother was in the office the other day, and her child was covered by a certain for-profit, commercial insurance...not to name names, but the company rhymes with "You lie, Ted."

Last year her co-pay on office visits was $20. As of Jan. 1 it rose to $40. She was not happy about this.

I wouldn't be pleased either. And I will go out on a limb and guess that her premium did not decrease. So this health insurance company gets the family to pay $20 more per office visit, and they get to pay $20 less.

That is an awesome way to make a profit: shift the cost to someone else!

Too bad I can't figure out a way to do that (legally, that is).

This same insurance company (whose letters can also be rearranged to form the phrase, "DIE, NUT") announced last year that it would finally start paying for both a sick visit and a check-up on the same day. Previously, it would only pay one or the other. Now most check-ups are pretty straightforward, and minor issues are expected: the baby has some cradle cap, my teenager has a little sniffle today. But every once in a while they present with something more complicated: a wheezing infant, a preschooler with bad behavior problems. If the insurance company won't cover both on the same day, I tell the parent: we can address the problem or do the check-up, but not both. (Expecting a doctor to do otherwise is like taking in your car for a tune-up, finding that your brakes are shot, and expecting the mechanic to fix the brakes for free, since "it's all part of the tune-up.")

Well, this nameless insurance company now says that due to computer issues, it won't start paying for both a check-up and sick visit on the same day until, oh, December 2007.

(Warning: sarcasm ahead.)

Dang, that must be a wicked bad computer problem. They must be getting some serious l33t hacker dudez to crack that code. Maybe they're asking both Steve Jobs and Bill Gates to work together on this one. I mean, how in the world would you program a change in a reimbursement rule? They must be outsourcing that one to, heck, every computer programmer in Bangalore and Boston combined. I hope they're at least consulting with MIT.

"Computer issues?" Really, couldn't they at least think of a better excuse? Though I admit it does sound better than saying, "we delayed the implementation to continue diverting money from the premiums to our shareholders."

I don't want to paint all health insurance companies with the same putrid brush, but as a doctor (or, as they say, a "health care provider,") I think the average person doesn't realize that these companies are first and foremost in the business of making money for their shareholders. If they can provide health coverage along the way, great, but they aren't in this for their health. Nor for yours.

A small indignation

A parent called this morning asking to have her 7-year old daughter seen for a cough. My receptionist offered her 11:00am today, to which the parent replied, "well, I can't wait that long. I'll just take her to the ER."
The parent called back 10 minutes later asking for the 11:00am appointment.

In my office we do our best to get sick patients seen on the same day. We'll sometimes double-book or tell people to come in at 4:00pm--"You may have to wait, but you will be seen." Children who sound really sick are asked to come in right away and squeezed into the schedule.

I have no patience for parents that think a same-day appointment is unacceptable.

First, two hours might get you seen in the ED. If they're busy, it might not. So we get you in for an appointment before the ED--a walk-in facility--could even see you. (Aside from the fact that the most demanding parents tend to have children with relatively minor problems which don't even warrant being seen in an ED.)
Second, try this with any other specialty. Call up your internist and ask for an appointment today. I'd suggest you could use a stopwatch to see how long they laugh before they compose themselves and ask you, "are you serious? Our first available appointment is in 1 week."
Third, try this with any other profession. Call up your auto mechanic. I dare you to throw a hissy fit if they can't squeeze in your timing-belt replacement in the next 2 hours. See if your hairdresser will bend over backwards to get you in for a perm in the next 20 minutes.

I understand we are dealing with sick children, and anxious parents. But we pediatricians seem to get the least respect and the most outlandish demands, for reasons that tend to have little to do with the acuity of illness and more with the convenience of parents. ("I can't make it at 3pm, I have an appointment. If you can't accomodate me at the time I want, I'll just find someone else who can.")

One of these days, in a world without HIPAA privacy regulations, I'm tempted to ask one of these demanding parents: here is a list of the patients already scheduled this morning. You're welcome to call them, ask if they would give up their spot for you, and call us back when you find someone willing to do that.

There's no upbeat ending or silver lining to this post, just something I had to gripe about.