NOTE: Another view from the frontlines written by my husband, Gary Bakst.
I saw a patient for a physical exam and there was a lump found on that exam. It was not one of those lumps that make you immediately think the worst. But it also wasn’t a lump that felt obviously innocent. It would require investigation. I was concerned but in my gut I thought this is probably going to turn out to be benign. I also knew that what I needed to do was fairly straightforward. The work up should be easy. However, what should be easy is hardly ever easy these days.
I knew he needed a CT of the pelvis with and without contrast to better understand what we were looking at. However, when I searched our electronic medical record system, there was no option for a CT pelvis with and without contrast. There was CT abdomen with and without. There was CT abdomen and pelvis with and without. There was CT pelvis without any specification as to whether or not it included contrast and there was CT pelvis with contrast. I have no idea why they made the choices so weird. Ultimately I decided they must have intended that the CT pelvis (without specifying) was without contrast. So I ordered CT pelvis with contrast and CT pelvis.
This electronic medical record system was imposed upon our office. We did not ask for it and we surely did not want it. We had an electronic medical record system that was working very well but the larger organization that we are now part of felt it was important to get everyone in the organization on the same platform. They switched us over a bit more than a year ago knowing they were going to again switch systems for the entire organization in early 2024. We explained to them that our office is particularly busy and they did not have enough support staff to make this cumbersome system work in the setting of such a busy practice. They weren’t impressed with that argument.
When the switchover came, they sent in people to help us with the transition and they were great but the underlying issues were too much to overcome. Our office became less productive, we were less able to accommodate our patients and new referrals. The larger organization lost money when they thought they would save money. Some of our doctors and PA’s became frustrated. Two have left and one went from full time clinical to half time clinical practice. We have been able to hire a PA and a nurse practitioner and we hopefully have another physician joining us soon. Still our productivity is well below where we were before the change. Belatedly the higher ups came to understand that the transition was a failure and allowed us more staff to deal with it. Unfortunately, that happened just as the economy got weird and you couldn’t hire anyone. However, as time went by, we have been able to increase our staffing and it has gotten better.
We submitted the plan for the CT pelvis to the patient’s insurance company and they rejected it. We appealed and they again rejected it and said I needed to speak to one of their reviewers. Ultimately, they finally approved the CT. Thankfully, it showed nothing terrible. I had also ordered some lab work for this patient. Previously, we drew the blood in the office and we also had a very efficient office lab that processed the blood work. It was accurate and very fast. The overwhelming majority of lab work was available to me on the day that the blood was drawn. I would go home from the office and be able to review all of that lab work, call the people who had a problem and create letters to those who had good results so they could know they were fine. Each evening, that day’s blood work was essentially all dealt with.
However, the larger organization closed our lab. We still draw the blood but the plan was to send it to their lab to save money. We explained that it would lead to delays and be less efficient and not allow us to do as well in dealing with issues that come up with lab work. However, they felt very strongly that it would be a major savings in lab costs. To be fair, the higher ups listened to our objections and we were able to speak with them at length about it. But the decision was made and was not going to be undone.
On the same day that they changed our electronic medical record system, they also closed our lab. Specimens were to be sent to the hospital but at the same time, the pandemic related supply chain issues got us. There was a shortage of vacutainer tubes needed for blood draws so we had to send all of our labs to Lab Corp except for those patients who have Blue Shield which does not accept Lab Corp. Lab Corp did pretty well getting us timely results. They took one day longer than our lab but they were not too bad. We lost much of our ability to have the lab add on tests as needed or re-run results that were questionable. Still, it was a moderate, not severe, drop in our function. For the Blue Shield patients, they had to go to either St. Peter’s labs or Quest labs, both of which were quite slow. Sometimes we just never got any results and we had to call for them. Sometimes patients would tell me their results off their portals for those labs and that is how I found out how they were doing.
Finally, in November, the shortage of vacutainer tubes was over and our hospital lab said they were ready to accept our labs rather than sending them to Lab Corp. But they were not ready. We saw labs taking 4 or 5 days to come back. In quite a few cases, by the time they got to our specimens, they had timed out and it was too late to run them. For reasons I cannot fathom, they denoted this as “lab accident” and that showed up on patient’s portals. Patients were naturally concerned about the lab accidents involving their results. I started sending them to Lab Corp again until the hospital was able to get enough staffing to actually process the labs properly. They are finally doing better but not great.
In my patient’s case, there were lab abnormalities that required follow up. I asked them to add the follow up labs from the blood that we had already collected but they could not do so. Previously that would have been easily accomplished. The patient came in for repeat blood work and they did much of what I asked for but somehow left out the most important follow up test. I am capable of making mistakes but I had correctly ordered it-they just didn’t do the test. Fortunately, in this case, they were able to run it and it also turned out to be good news.
I have spent a fair amount of time criticizing the larger organization that owns our practice but I want to make the important point that they are actually pretty good as larger organizations go. The problem with them is that they are a larger organization. Speak to doctors anywhere in the country and you will hear similar stories. Mostly you will hear worse stories. These guys are really only guilty of being a bit too smart to realize that sometimes when something works, you should let it keep working rather than fix it. Other organizations do far worse and have more concerning priorities. The main point is that we now live in a landscape of practices owned by large organizations in which the decision makers are removed from the people taking care of the patients. They have their own data and jargon and don’t answer to us. Another part of this is the insurance companies which are increasingly difficult to deal with. Then there are the ridiculous costs of pharmaceuticals and the shortages of all kinds of common products from blood pressure medications to amoxicillin liquid.
Ultimately, this patient is well and that is the most important piece of news. And in the end, we were able to get done what we needed to get done. But, comparing what it took to make it happen to what that would have involved just a few years ago, the difference is quite stark. People talk about the problems in health care these days. You are not imagining them. This was a fairly straightforward case. Nobody was hospitalized; nobody had surgery. It was just a CT and a couple of labs. But it shouldn’t be this hard.
Stories I Tell Myself 
A great well written inside look on how so many doctor’s office have lost efficiency when taken over by large organizations. Three years ago one of my doctor’s office was taken over by a large hospital. Although the doctors have remained their support staff has turned over repeatedly. I can see the frustration in my doctor’s eyes. Last month at the completion of my appointment I’m waiting at the reception desk to make my next appointment. The staff member actually told me that she did not know how to do that. She needed to wait for another staff member to come back from break. Over the past three years that this practice was taken over every time I have had an appointment there is always new staff members working to support the doctors. It’s not only frustrating to the doctor, but to the patients as well.
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As one of the the driving forces in Albany for the establishment of an electronic medical record (EMR), I concur wholeheartedly with the pitfalls of joining an organization that ignores the pleas of the end-user.
In 1994, I began using an EMR (called Medifile) as a solo user in our group, to perfect the program and modify it to enhance the efficiency of record retrieval (“where’s the chart?”).
Simultaneously, data input algorithms (and templates) were created to make record keeping more organized and faster than traditional dictation.
Notes concerning a visit could be essentially completed by the time the patient left the office while still able to face the patient (once laptops became available). Six years later as the year 2000 rolled around, the entire practice began using the record ( this did meet with some resistance among the docs, but eventually most, if not all, saw the benefits and adopted the technology).
This allowed decades of data (both notes and labs) to be stored and retrieved; this was complemented by the ability to scan reports from elsewhere (xray, EKG’s, notes from other physicians).
When we were acquired by ALBANY MED, we made sure that our ability to maintain this program would be assured for at least the initial 5 years; In fact, because the medical center had other priorities, that grace period extended to November 2021 ( a total of 7and 1/2 years). The calamitous transition that Gary has described occurred after my retirement. The impact was underestimated by the powers that be; all the more ridiculous as the medical center, already recognizing the faults in their system, already had planned to change their system (and thus require the Endocrine group to transition a second time in 2024….. although the inherent inefficiencies in these plans will likely delay that transition).
Nevertheless, with each new iteration of a medical record that doesn’t resemble the prior one in use, a new series of inefficiencies will be thrust upon the end users again, causing more angst for the office and the patients.
While the business of medicine was made easier by the acquisition (collections from patients, fighting with insurance companies for appropriate reimbursement, etc), the practice of medicine has been made more complicated.
As in most large organizations, the soldiers are given orders; the generals, not in the frontline, are oblivious.
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I do vaguely recall that resistance to the initial introduction of the electronic medical record system. I am pretty sure the guy resisting the most looked just like me, except younger. Little did I realize then how much I would come to appreciate that system. Thank you for the wisdom and foresight and for the institutional memory.
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