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My hospital’s IT infrastructure is absurd. The best satirist could not describe it, although it conjures up scenes from Mike Judge’s Office Space, if one replaces progress notes with TPS reports.
It is 6 am and I get my portable computer on wheels for my morning rounds. The bulky machine includes a full desktop PC, battery pack, monitor, keyboard, and mouse. It weighs about 75 pounds and is to be my millstone for the next several hours.
I log in. Password regulations dictate my 24-character string of letters, numbers, and emojis be changed fortnightly. I am habitually typing the old password. On eventual success, the computer takes a full minute to reach the log-in to the virtual desktop. Once again, username and password and a minute-long wait to reach the virtual desktop where resides the electronic medical record (EMR) application. Now, to log into the EMR, another flurry of keystrokes, username, password, and a minute-long wait. The radiology software also requires the familiar pattern of taps across the keys followed by a delay.
My coffee has cooled to room temperature. We are nearly ready to begin rounds.
As I wheel my albatross to the first patient room, I introduce myself to the patient. They are unlikely to remember my face, as it is obscured by the large monitor. I type as we converse, recording the various bits of information needed to maximize our billing department’s reimbursement for my note. The more information I include, the lower my chances of nasty emails telling me to add to my documentation. Fewer than emails a day is a victory.
I apologize to the patient for the lack of face-to-face care. There is limited time before I’m needed in the operating room. I’ve tried not typing while talking to the patient. Typing between patient rooms delays progress enough to make completion of rounds prior to surgery impossible. Typing after a full day in the OR brings a host of other problems: provider teams lack documentation of my daily plan; I forget things; I end up typing from home, late into the night.
So, I type and talk. I fill out my essay, the only evidence of my hard work, my only valuable product according to the billing department. No note, no money. (I am occasionally reminded how valuable my notes are; If an emergency comes in and I am tardy on my signature, I immediately receive nasty emails stating my neglect is costing the hospital some ungodly seven-figure sum of money.) After completing my documentation, I assign it a diagnosis code and a billing code (another 30 clicks or so to complete) so my employer can eventually sell the note, either to an insurance company or the government.
I walk into one of the many Wi-Fi dead zones in the hospital. My screen freezes and I pray that is all. If my virtual desktop drops, it is another few minutes of frustrated password typing and annoyed waiting. These drops and freezes conveniently happen at the doorway threshold of every patient room, down the major hallways, and in front of the elevators.
A patient needs an MRI order. Another 80 clicks consume the next two minutes of my time. Not only must I complete the various fields in the order (when, where, how, and why), I must assign another diagnosis code and fill out the “appropriate use criteria (AUC),” mandated by the federal government. The AUC program came about since some politician decided doctors were ordering too much imaging. Now, to order a CT or MRI, in addition to the cumbersome EMR ordering process, I need to justify my choice of imaging. There is nothing like a computer algorithm questioning one’s clinical judgment to get the blood running hot. “Because I’ve completed eight years of neurosurgical subspecialty training, published multiple textbooks, and am an expert in the field” is not a valid reason for ordering the MRI, apparently. It is another 20 clicks or so to navigate the popup boxes, find the “appropriate” diagnosis code and order the scan. The system has no shortcuts when a patient is actively dying, either. The clicks just become more furious.
I then need to book a patient for surgery. There go another 100 clicks. I still manage to get the booking wrong and will need another 5 phone calls with the OR front desk to rectify it.
Every click was sold to us as “only taking a few seconds.” Administrators and bureaucrats were not lying when they said that. They simply forgot to mention that they will keep adding clicks: another popup box to navigate, another order entry field to complete, another variable to document. The clicks add up to minutes and hours.
Of course, the government decreed that nurses or less-highly-paid staff cannot put these orders in themselves. The physician must do it. So, I remain tethered to my computer.
When I finally leave the hospital, I am not off the hook. I take calls, from home, for a week straight. I am on my couch and the ER calls me. There is a patient with a head trauma and the ER doctor is trying to describe a head CT over the phone. I need to see the images myself, as my own visual interpretation is the difference between me breaking the speed limit to get to the hospital or a leisurely drive. The only possible way I can see the CT is if the ER doctor scrolls through the scan while I watch over FaceTime.
No other industry has harnessed technology to decrease efficiency like healthcare has. The regulations around EMR have stifled what should be a highly competitive market. The billing and quality metric reporting regulations make an oppressive documentation burden for doctors and nurses alike. Forcing EMR on hospitals via governmental mandate has led to unsuitable infrastructure.
I have better Wi-Fi coverage in my house than our billion-dollar-a-year hospital has. My $500 personal laptop is both lighter and faster than the behemoth computer lassoed to my neck. I can watch the entirety of Breaking Bad on my cell phone almost anywhere in the country, yet there is no way to send the greyscale images of a CT or MRI over an app.
These are not failures of the free market. They are textbook examples of government regulation stifling an industry. The documentation burden is secondary to Medicare rules on billing and quality metric reporting. For example, in one year of trauma surgery, it takes 73 full 24-hour days to complete the required documentation for billing alone. In ambulatory practices, physicians spend two hours on the computer for every one hour of patient time. There are 2,266 quality metrics used by CMS and over $1 billion has been spent developing those metrics. Meanwhile, physician practices spend $15 billion annually just reporting their metrics. These are regulations that take physicians away from the bedside and, ultimately, lead to burnout.
As I type my 24-character password for the 18th time in a day or am squinting to interpret a CT scan over FaceTime, I feel that burnout. How much better would my life would be if I just took cash-pay or liability patients. I could make a good living doing medicolegal expert witness work. There is a reason doctors, especially those older and financially secure, are leaving the industry in droves.
For now, I deal with the satirical infrastructure, password reset reminders, and Wi-Fi dead zones. At the very least, they provide fodder for my rants here.Published in