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So, the question has been raised: why am I doing this?  Why re-invent the EMR wheel?  What is so different about what I am doing that makes it necessary to go through such a painful venture?  I ask myself this same question, actually. Here's my answer to that question:

What medical record systems offer

What I need

High focus on capturing billing codes so physicians can be paid maximum for the minimum amount of work.

No focus on billing codes, instead a focus on work-flow and organization.

Complex documentation to satisfy the E/M coding rules put forth by CMS.  This assures physicians are not at risk of fraud allegation should there be an audit.  It results in massive over-documentation and obfuscation of pertinent information

Documentation should only be for the sake of patient care.  I need to know what went on and what the patient’s story is at any given time.

Focus on acute care and reminders centered around the patient in the office (which is the place where the majority of the care happens, since that is the only place it is reimbursed)

Focus on chronic care, communication tools, and patient reminders for all patients, regardless of whether they are in the office or not.  My goal is to keep them out of the office because they are healthy.

Patient access to information is fully at the physician’s discretion through the use of a “portal,” where patients are given access to limited to what the doctor actively sends them.

A collaborative record, sharing most/all information with patients so they can use it in other settings for their care.  Also, I want patients to have edit privileges for things they better suited to maintain, like medication lists, demographics, insurance information, and past history items.

Organization of information is not a high priority, as physicians are not reimbursed for organized records.  The main focus is instead on meeting the “meaningful use” criteria, which gives financial incentive to physicians who use a qualified record system.

Since the goal is to share the record and to maximize care quality to make communication more efficient, organization of the record is crucial.  The goal is to put the most important information up front and to give easy access to the details sought.  I am the “curator” of the record, organizing it and prioritizing information in a way that is useful to both me and my patients.

Top priority is paid to billing workflow, with second billing given to in-office patient management (not apparent to most patients).  The least attention is given to clinical workflows for patients outside of the office.

My priorities are 180 degrees from this.  My top priority is keeping people outside of the office healthy and happy (which will keep them paying their monthly payments), so maximizing organization and communication need to be the focus of my records.  Certainly in-office care needs to be efficient, but not in the same way as the rest of the healthcare system (efficient documentation for payment); it must focus on getting the most accurate information into the system and making it easiest to get information out.  Billing is almost a non-issue, as it is very simple in my system.

Task management is again a low priority, as it increases potential non-reimbursed work for physicians (and staff) in the typical office.  For example, there is not much emphasis put on phone office follow-up or making sure the plan is communicated to the patient.  This is not strictly avoided, as most medical professionals do want to give good care, but the high-stress overworked atmosphere in most offices makes most medical personnel reject any tool that gives “extra work.”

Task management is near to the top.  I am focused on coming up with a care plan for each patient and making sure the patient understands that plan.  The goal is to reduce the chance of misunderstanding, as it increases my work and decreases the patient’s chance for health.  So an integrated task-management tool is very important, as is education resources which can be accessed directly from the patient record and given to the patient to keep (ideally) in an online “folder.”

Mobile communication is becoming more available, but it is very much system-centric, meaning that it is built by the EMR vendor to only be used by patients of physicians who use that EMR and to only be for viewing information from the physician, not as a patient-centered tool.

My goal is to give patient access to accurate medical information and access to me in a way that is easy and efficient.  Mobile technology is the most obvious means to this end.  I want patients to be able to access their entire record, not just what I generate, from a mobile application (or at least a web application).  I want any place they get information to also be the communications hub, as it allows them to communicate with as much information as possible.  In short, I am looking to have a “one stop shop” for all patients’ needs, not a “walled-garden” that only gives them access as long as they see a doctor that uses the system.

Payment for health services generally depends on two things: a problem being treated and a procedure code.  These are both, therefore the focus of the record system.  Problem lists are in the record, not primarily because they help with care, but to allow billing for services.

I believe we should focus far more on reducing risk factors than on treating “problems.”  My goal is to avoid problems and do fewer procedures when and where at all possible.  Problem lists should not be focused on code, but instead to give the most accurate information to lead to the best decisions, and to help understand the risks the patient faces so problems can be avoided.  If this happens, I will have less procedures, a fact that will make both me and my patients happy.

Optimistically, the ultimate goal of the typical EMR is to allow a physician to practice the best medicine possible while not going out of business.  It allows physicians to give good care despite the system that rewards them for bad care.

The goal of my record system is to promote the success of a new business model: pay doctors more to keep people well and to keep people out of the rest of the health care system.  The ultimate goal of this record system is not to make money for me as software I can sell, but to make it so I can extend the model efficiently to a larger population, ultimately making this new system of care an attractive enough alternative to physicians, employers, and patients to make the switch.  Perhaps in doing so the “do more, spend more” system can be replaced by a welcome alternative.

So here is the goal:

  • Create a prototype of a system that allows me to give my system of care efficiently to a large population.
  • Use that prototype to “prove concept” - that the care I give is better for patients, better for me, and saves money.
  • Create enough interest in the model that people are willing to develop the system. I think this is best done through making it open source and setting up a foundation to fund the program (and let me gladly hand it off to people who are better at this than I am).
  • This will ultimately lead to more adoption of the practice model (by making it easier to make the transition), which will in turn lead to more interest and funding in the software.

I don’t believe we can retro-fit a standard EMR product to do this job; I think their focus is too different from the goals of this practice model. I may be wrong, but I looked at numerous systems and found that they fought against my goals instead of enabling them. I turned to this idea not out of ambition, but out of a desire to survive and see my practice model succeed.


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I have made a very big decision: I am going to unplug myself from the internet world for a while.  That means that I am hanging up my blogging for now.

Things are OK with me – 2010 has actually been a very good year for me personally – but I know that things can get better.  I have lived my life on this and other stages, getting the praise (and tomatoes thrown) that such a life can bring.  I’ve actually had more than my share of good things.  But I have so put myself into that person on the stage that there has been far too little time for the person behind the makeup, and for those he is close to.   This is a very big step to take, but I think I am taking it for healthy reasons.

This is an open-ended decision; I don’t know if/when I will plug back in, as I don’t really know when it will be good for me to do so.  I just know the start of this chapter, not how it ends.  Part of me hopes that I will be back at it soon, but I mean to really put this down, not just take a rest.  I will only pick it back up when I know it is the right thing to do.  If I do pick it up, it will be only for the right reasons.

I walk away now with gladness for what this part of my life has given me.  I don’t regret or look negatively on what it has brought me, in fact I see it as a very great thing.  I just know it is time for me to look to the guy who lives off of the stage and to those whom I love.  Life is bigger than all of this.  Life is more than the applause and the acclaim.  Perhaps I have made this too big a part of my life, especially the thrill at the sound of the applause.  When it comes right down to it, we are all people who go home and live in our own skin.  We should strive to live well in that skin we have, for the days that are allotted us.

A lot goes on behind the scenes, and over the past four and a half years I have had very much, both good and bad, happen in my life that has not made it to this blog.  The same is true for all of my patients and all of my readers.  We are much more than the persona we put out for others to see.  Each person we meet is far more than our perception of them.  We do well when we remember that fact.

Thank you to all that have made this such a pleasurable adventure.  Thank you to all of the friends I have made – you are truly friends, friends in real life.  I may be harder to reach than before, but I will still (God willing) be here.

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Repost: Real Meaning

The following was originally posted on 12/22/2008.

Every day I go to work and spend time with suffering people.  They come to me for help and for comfort.  They open up to me with problems that they would not tell anyone else.  They put trust in me – even if I am not able to fix their problems.  I serve as a source of healing, but I also am a source of hope.

Christmas is a moving season for many of the same reasons.  No, I am not talking about the giving of gifts, or the time spent with family.  I am not talking about traditions, church services, or singing carols.  I am not even talking about what many see as thereal meaning of Christmas: Mary, Joseph, shepherds, wise men, and baby Jesus.  The Christmas story most of us see in pictures or read about in story books is a far cry from the Biblical account.  The story we see and hear is sanctified, clean, and safe.

Before I go on, I want to assure my readers that I am in no way trying to persuade them to become Christians.  I am a Christian, but whether or not you believe the actual truth of the story, there is much to be learned from it.  I find it terribly hard to see the real Christmas story here in a country where the season is filled with so much else – much of it very good.  It is far easier to just be happy with family, friends, giving gifts, singing songs, and maybe even going to church, than it is to contemplate the Christmas story.  I think the Christians in our culture have gotten way off base on this – much to our shame.

Christmas is not about prosperity and comfort, it is about help to the hopeless.  The central doctrine to this season is the incarnation: God becoming man.  God didn’t become a man because he thought it would be nice to spend time with us; he did so because we were hopeless.  He didn’t come to live in comfort, but to be poor.  He didn’t come to help good people, but to rescue the outcast.  He didn’t come to hear cheers for saving people, he came to be rejected and so to identify with rejects.  He scorned the self-righteous, and embraced the shameful.

What about the Christmas story itself?  Mary got pregnant out of wedlock and Joseph chose to bear the social shame.  They were in a country that was occupied by a foreign empire, ruled by self-seeking despots and self-righteous religious leaders.  Jesus was born in a barn -  not the clean manger scene we are used to.  The birth was announced to shepherds – people who were scorned by the “good” people of society.  The local ruler was so worried the messiah would overthrow him, he sent death squads to murder all children under two in the town where Jesus was born.

Fact or fiction, the scene was not pretty, but instead was filled with pain, despair, and hopelessness.  This is hardly what we see on TV.  This is hardly what we hear in church.  That is the setting describing the first Christmas, not a mall or warm living room with a tree.  Christmas is doesn’t hide from pain, it addresses it.

Whether you take it as truth or just as an inspiring story, we should pay far more attention to this meaning.  Yes, it is great to give gifts and be with family – I will be doing that as well.  But there is no escaping the pervasive pain and suffering in this world.  The Christmas message is not about sheltering ourselves from that suffering, but instead going out among the suffering and providing comfort.  The lonely woman weeping in the exam room or the drug-seeking addict who is trying to pry a narcotics prescription from me – they are the ones to whom this Christmas message is proclaimed.  Whether you do it to imitate God or simply to be a good person, we can perpetuate Christmas by helping instead of hiding.


To those who spend little time around the suffering of others, I urge you to break out of the cozy shell and really celebrate Christmas.  Pain and suffering are not far from you; even in our affluent society.  What I encounter in my exam room has convinced me that society is obsessed with denying this truth.  We have made Christmas into a comfy commercial family time, when the real meaning is something far more profound.  If you don’t feel adequate to help the suffering, then let me offer this: medical professionals are no more morally upright than the rest of society, yet we are honored with the task of helping the suffering.  We are no better than you are.  Really.

So go out there and have a great Christmas.




As I was listening to the songs “Sleigh Ride” and “Rockin’ Around the Christmas Tree” for the 12 gazillionth time, resigned to the fact that my mind would cruelly replay it for the rest of the day, I began to wonder why that happens.  Why do incredibly annoying songs get stuck in our heads?

Then I realized that  I’ve written a post on this very subject! I talked about Goober Peas and earworms.  How could I forget?

Sigh.  I think I am going nuts.  I don’t remember the extensive research and labor involved in the process of coming up with that post?*  Clearly the problem is the incursion of evil Christmas songs into my head, including:

  • Sleigh Ride – I am told that Ella Fitzgerald does a great version of this, but obviously it is not a auricular nematode.  All other versions are clearly inventions of Christmas haters.
  • Rockin’ Around the Christmas Tree – We will have a sentimental journey: the sentiments of loathing, revulsion, angst.
  • Simply Having a Wonderful Christmas Time – A local radio station that my nurses listen to has committed itself to playing this song at least 4 times every hour.  I think it’s a conspiracy with the local liquor stores and psychiatrists.  I am seriously considering both.
  • So This is Christmas – Giving Lennon equal time to ruin our lives.
  • Santa Baby – Need I say more?
  • Grandma Got Run Over by a Reindeer – Funny once, when I was a child.  I think I was drugged.  I was also unconscious. It was funny then, but NEVER AGAIN.

I hope this post hasn’t put any worms in your ears.  If it does, you can always do what Bill Shatner did:

Khan!  Khan!  No More “Santa Baby!!!”  Khan!!!!!!!!





To Die Well

Everyone liked him.  Though his later years (the only ones in which I knew him) took away his ability to do most things, and though he was in great pain every day, it was easy to see the mischief in his eyes.  The subtle humor was still there, coming out of a man who was weak, in pain, dying.

She lived for him.  She was always telling me of his pain, frustrated with the fact that he didn’t tell me enough.  She was anxious about each complaint of his, wondering if this was the one that would take him away from her.  Many of her problems were driven by this anxiety and fears, and she spent many hours in my office giving witness to them through her tears.

As his health failed, I wondered at her future.  He was the center of her life, the source of her energy, joy, purpose.  How could she manage life without him?  How could she, who had so much lived off of the care of this wonderful man, find meaning and purpose in a life without his calming presence?

Then he died.

I saw her in the office recently, and was amazed at the look in her eyes.  It wasn’t the empty, lonely look I was expecting.  It wasn’t the worried, helpless look that I had seen so many times.  It was peaceful, content.

“You look good,” I said, wondering at what I saw.

“I miss him a lot,” she said – something that really didn’t need saying.

“You look…content, much better than I expected,” I responded.

“I feel content.  I miss him so terribly, but I am so blessed that I could be with him when he died.”

When his health failed, I called hospice to take away much of the worry and fear.  I wasn’t sure how well she’d accept that help, but she did, and his death came fairly rapidly.

“He died in my arms,” she continued.  ”For the last two hours of his life, he just lay in my arms.  He didn’t say anything to me, but I am sure he knew.  I just held him.”

“I’m glad you could do that.  I want people to die with their loved ones around them.  It’s a sacred thing, something very intimate.”

“Yes, it is,” she said, looking up at me and smiling.  ”All of those years we spent together, and I got to be with him until the very end.  He was mine, and I took care of him.  Now when I think about how he died, I get meaning and purpose.”

I thought about this as she left the office.  I’ve seen many people die, and have helped many through the grieving process.  I have witnessed the loneliness, the pain, the loss, and have done what I can to comfort.  But this woman took comfort in something unexpected: she took comfort in her husband’s death.  The story ended up in such a fulfilling way that the pain of loss was eclipsed by the joy of a life with her husband.  The way he died made all of the love and all of the shared life close in a way that wasn’t tragic, it was climactic.

That is what it is to die well.  Death is inevitable, but it is almost always seen as tragic.  Yet his death was a culmination of all his life had been.  His memorial service, she told me, was filled with people telling of his wonderful demeanor, his wry humor, and his caring heart.  So to her, the story ended up in a most satisfying way.  The intensity of the loss only serves to emphasize the glory of the life.

May we all die so well.



Unholy Night

I posted this two years ago, and some folks may have heard this, but this is my very favorite rendition of  ”Oh Holy Night.”  It touches me like none other.

If the above audio player does not work, click on this link

By the way, don’t play this where anyone can hear.  It may frighten children and small animals.



Ask Dr. Rob: The Hand that Freezes

OK, so I’ve done this thing called Ask Dr. Rob, in which I answer questions that my readers have regarding health, tacos, webkins, fetuses driving speed boats, the end times, baby spit, the dangers of kumquats, and other crucial issues.  But there is a big problem: nobody ever asks me questions anymore.

So I asked myself: why is this? Why don’t people ask me questions?

Then I answered myself: well, you just asked me a question!

Then I said back: Yeah… but I am me, and that shouldn’t count, should it?

To which I answered (in a very snarky tone): There you go again!  You keep asking questions!  Aren’t you good enough for you (or me)?

I pounced on this: Hah!  Now you are asking me questions!  Caught you!

Then I stormed out and left myself alone.  I still haven’t seen me, but it did start me pondering the fact that I could ask myself questions.  I did this without asking a direct question (so as to not raise a ruckus), but wondered this:

I think a question I would ask myself (If I would do such a thing) would be about the coldness of doctors hands and if there was a reason for it.  I think that this would, hypothetically, be a good question to answer (as it were) on the “Ask Dr. Rob” segment.

Then my doctor increased my dose of medication and everything got better.

But hey, why not answer the mystery of doctor’s cold hands?  These hands of mine cause babies to cry when touched; they take away my patients’ ability to breathe for several minutes, and cause asystole at least once a week.  My hands get so cold at times that I was contacted by Al Gore to see if they could be used to combat global warming.

I am considering it.

The Science

In the mean time, let me explain to you (and me, if I ever come back) the science behind cold hands.  Yes, it is science,not magic.  It does not involve he-who-must-not-be-named or horacruxes (though my patients may disagree with that).  It is science because it relies on the basic laws of nature, namely: the laws of thermodynamics, which include the following:

  1. If you have no energy, you won’t get it; and if you have energy, it will changed from one kind to another (probably making you feel like you have none).
  2. Heat will move from the hotter thingy to the colder one until they are both the same temperature.  The colder one won’t make the hotter one even hotter, which is too bad because my air conditioning bills would be a lot less if it could.
  3. The colder things get, the less they move, and if things get really, really cold, they give up even trying to move.

Now, some idiot scientist got all smarty-pants and said “Well, actually there has to be another law before the first one”, and so instead of shifting everyone back in line, they made it the zeroth law.  I think they did this to insult that scientist.  This law states:

  • If two thingies (let’s say they are gerbils) are just as cold as another thing (let’s say it’s a wrench), then the gerbils are just as cold as each other (although one will invariably complain more).

They didn’t talk about gerbils and wrenches in the law when they made it, but it does make it more interesting.

Much more interesting.

In truth, these laws are pretty obvious, and many people don’t understand why they were made in the first place.  The laws were actually voted on during the presidency of Millard Fillmore, who wanted to make the youths think he was a cool dude.  He figured that kids liked physics, as Albert Einstein was all the rage at the parties, he wanted to jump on the “hip physicist” bandwagon.  Nobody was fooled, though, and he was never invited to the cool parties.

Despite this, the laws still stand, even the one before the first law.


The Application of the Science

So, you may ask (because I wouldn’t dare), what does this have to do with doctors’ cold hands?

1. The Conservation of Energy

Certain patients come to the office constantly complaining that they have “no energy.”  These patients are wrong about this, they actually have energy and consume huge quantities of it.  They actually are energy magnets, drawing all energy from their environment and storing it in their thymus gland.  You may have met this kind of person before; they often attend office parties.

This is what is known as the conservation of energy, which is the first law of thermodynamics.  Why does it conserve energy?  The reason is that these patients never use the energy they store in their thymus gland.  The heat energy in the hands of the doctors is removed by these patients, and not wasted on the comfort of the other patients.

Some scientists are looking into ways to tap this abundant store of energy in the thymus glands of these patients.  Unfortunately the scientists themselves don’t have the energy to complete these experiments.

2. Entropy

The second law states the obvious fact that cold things don’t make warm things warmer,  If someone sticks an ice cube in your pants, it doesn’t feel warm.

At first glance, this doesn’t seem to have to do much with doctors’ cold hands (unless they are the ones who put an ice cube in your pants), but a central concept to this law is the principle of entropy. Entropy is the tendency of things to get disordered over time, the mortal enemy of people with Obsessive Compulsive Disorder.  It turns out that things that are cold are less disorderly than warm things, or conversely, warm things have higher entropy.

There are many examples of entropy in the day-to-day world of a doctor:

  • The state of the insurance industry – creates chaos and disorder in the lives of medical professionals.
  • The medical record – disorganized and incomplete.  Attempting to keep order in this realm is a battle against chaos.
  • Doctors’ handwriting – nothing more need be said.

So you see, each of these chaotic things in the day of a doctor requires heat to cause such disorder.  This heat is sucked out of the hands.  If enough heat is removed, it will cause permanent freezing to the heart.

3. Absolutely Freezing

The third law states that cold things don’t move as much as hot things, and really, really cold things stop moving altogether.  While this law does not explain the coldness of a doctor’s hands, it does explain a troublesome phenomenon.  Why do doctors run late?  Simple: their hands are cold, which causes them to slow down progressively more throughout the day.

In response to this, doctors have turned the temperature of the exam rooms, attempting to accomplish two things:

  1. Slow the patients down so that the relative perspective of the patient is that the doctor is operating at normal speed.
  2. Some theorize that lowering the temperature enough will even cause time to slow down, creating a eddy in the time/space continuum where the patient sees less time pass relative to normal time.

This theory explains why doctors are slow to adopt computerized records, as the extremely low temperatures in doctors’ offices has caused the slower passage of time.  One office in our city is actually still in 1964.


So there you have it.  As you see, an understanding of  science allows complex problems to be simplified.  It’s not magic, it’s science!

Me: Wait!  You forgot to explain the application of the zeroth law!

Myself: So you’ve finally decided to come back, have you?

Me: I was over at Kevin MD’s blog, but I could hear through the walls.  It sounds like decent science, but what about the Zeroth law?

Myself: The one with the gerbils and the wrench?

Me: Yeah, that one.

Myself: It actually has no place in medicine.  The law is restricted to the plumbing industry.

Me: And the Gerbils?

Myself: They turned out to be horacruxes and had to be destroyed.



On Vacation


I am on vacation this week (in the land of the Mitten).  I have a few posts on the schedule, but don't expect any responses from me.  I am going to try to be a good boy and stay away from the addiction obsession Internet.

Have a great week.