Someone asked Mark Zuckerberg why harvard students – all strangers – would just give him all their personal information. “I don’t know why. They ‘trust me’ – dumb fucks,” Zuckerberg said. And social media was born. Everyone now knows the common cliché that in social media, you are not the customer. The sites are free to use. They enable you to connect with some guy in high school you haven’t spoken with in 20 years and in exchange you give them all your personal information. It’s just like Publisher’s Clearinghouse Sweepstakes but without the prizes.
Something similar is happening in medicine. One would think that the patient is the customer here. The patient goes to the doctor and expects to be treated. But who is the doctor obligated to treat? Conventionally, we assume that it’s the patient. But that’s not what the doctor gets paid for. The product of the visit is a note. The note must have certain elements in it to be able to be billed. Who defines those elements? Several historical practices have informed the structure of the physician’s note, but today the final authority of what must go into the note is Medicare – and all other insurance companies take their lead from Medicare, which accounts for the majority of medical payments in the US. So ultimately, if the physician expects to be paid, it is not the patient that must be satisfied. It is Medicare. Because of this, the doctor no longer gets to choose what portions of a traditional note are relevant for a particular patient encounter. The note template is now boilerplate, and the elements must be present or it’s not a complete note. (For instance if you’re seeing a 90 year old patient with severe vascular disease who smoked his whole life, as the doctor you don’t get to decide that Family History is irrelevant. If you don’t document a Family History, Medicare does not view it as a complete note. And there are many such examples.)
One way Medicare attempts to throw the focus back on the patient is by using HCAHPS scores (Hospital Consumer Assessment of Healthcare Providers and Systems) – AKA patient satisfaction scores, but they are hopelessly flawed and have no bearing on the reality of the situation, so that is really just a charade. In reality – under a traditional system – the patient finds that he has no control over the visit at all. The patient cannot see the doctor when he wants, often waiting 3-6 months. The patient cannot talk about what he wants, visits are limited to one problem only. The average time spent during the visit is also not dictated by the problem at hand, but by the volume of patients that a physician must see on a daily basis to remain solvent. The patient is the product. Not happy with this system, the patient ultimately gives the doctor a poor score when asked, even though all of these issues are outside the control of the physician.
But at least doctors are there to treat the patient in front of them, right? It gets even more complicated from there. The work product of a visit is a note. It used to be that a note was a way of communicating with other doctors and nursing staff. Now the note is the sole basis of all reimbursement and the sole arbiter in all legal matters. And notes are now written using an EMR (Electronic Medical Record). These systems promised to bring medicine into the future, but it is by now well known that EMRs are deeply flawed, These systems where born in the ’90s and haven’t evolved much since then. They can’t even run on modern computers. Instead, all of them must first open a small window that runs a sandboxed version of Windows OS from the era of their inception and then open the EMR software inside of that. And the screen resolution and window size is still what would have been used on cheap monitors from the ’90s (so you can never see everything at once), even though the windowed EMR now often takes up only about 1/3 of a modern screen. EMRs have not launched medicine into the future, they have locked medical documentation in the past.
And then there were the other promises. We were promised that EMRs would save time, but we discovered that they add significantly more time to each patient encounter as physicians deal with multiple required documentation and click-boxes in these cumbersome systems. Things that used to take a few seconds now take several minutes, so that now there is often not enough time during the work day to adequately document the patient encounter, a problem we are told to embrace as we do unpaid work at home, now called “pajama time” (as though we are supposed to enjoy this). We were also promised easy portability between hospital systems, but it’s now more difficult than ever. I recently requested documents concerning a patient’s visit at another hospital and received two entire charts full of faxed records each 6 inches thick (and they faxed it twice for good measure). These records were full of all the useless information that any physician would be familiar with: pages of labs for each day repeated multiple times in multiple formats, nursing notes which copy and paste from the same physician notes, entire physician notes with those same labs and scans repeated, patient information forms, Medicare notifications to the patient and any scrap of documentation that could be conceived of. In that entire stack there was one piece of information that was relevant to the request: one MRI report (that was sent multiple times in multiple formats along with all the other scans that were done). And then when I requested that the MRI images be sent so that the neurologist could review them, they said that the only way they could do that is to physically mail a CD – which would take up to a week! This is not a modern system.
Regardless, based on these false promises – and the general impatience with EMR adoption on the part of government – EMRs were mandated to be adopted by the ACA, with a penalty for not adopting them starting in 2015. But now we know that EMRs were mandated in their infancy, and once mandated, it virtually guaranteed that they would not mature any further. Why should they? Doctors have no choice now. They have to use them regardless.
Despite this, there is no way for the doctor to work to improve on the EMR experience because the doctor is not the customer, either. Health care systems purchase EMRs not to help doctors or patients, but to satisfy regulatory requirements. The doctor is what they call a Captive User and has no say in how the program is designed or used. It doesn’t matter that not one of the promises of EMRs ever came to fruition. There is no way to switch to a different program if you’re unhappy with the user experience.
In this system the physician is also the product. It is not a doctor/patient relationship. That notion is now so quaint as to be comical. Instead we find that the doctor/patient duo is packaged and bundled as a basket of goods that is bought and sold by hospital systems and clinics to the various payers. The system has completely lost track of who is being served. Patient treatment is not the focus, and if it occurs, then it is merely by happy accident. When an organization loses track of its core values, it allows all manner of corruption into the encounter. In the corporate world this is called Mission Creep, and it is how large corporations die: they focus on side projects that are not their core product or skill set and then become hopelessly confused about what their product actually is and who, in fact, is their customer. The bad incentives that are created can harm the company itself – like when a car company wastes time and energy making thermoses – or harm the customer directly and even result in illegal activity – like when Wells Fargo – with a core mission of “what’s right for our customers in everything we do” creates employee incentives that result in “an extensive and pervasive pattern and practice of discriminatory and illegal credit practices across multiple lines of business within the bank, resulting in significant harm to large numbers of consumers,” This discongruity manifested in up to 2 million fraudulent accounts being opened by employees of the bank in customers’ names in an effort to meet aggressive sales quotas set by the company leadership.
The mission of an organization can’t just be some mission statement posted on the bathroom bulletin board. The company has to be structured in a way that makes its core product the focus, and we don’t have that in medicine. What we have are mission statements that say all the right things and a business structure that incentivizes the opposite. The physician is then expected to bridge the gap between intentions and incentives. Most do everything they can to fill that gap, but ultimately it’s not possible for the goodwill of employees or physicians to correct for the bad incentives that are baked into the system. Incentives matter, and incentives trump intentions in the long run. The patient is not the customer any longer, and we don’t even know what the core product is anymore. When that’s the case, seeing a mission statement that is completely contrary to your own experiences does not motivate one to “be better,” instead it engenders extreme cynicism. No amount of shaming physicians with poor HCAHPS scores can make up for the fact that the incentives are wrong from the beginning. And if doctors are not serving patients, who are they serving? As Bob Dylan said, you gotta serve somebody. If the answer isn’t clear from top to bottom, the chances are good that we’re serving the wrong masters.
