Stakeholders by David M. Novick

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I have an MD degree, so I know I am a physician, even though I am called a “provider.” And I know that the “clients” and “consumers” I treat are really patients. What I did not realize, initially, is who the “stakeholders” are.

Back in the carefree halcyon days of my early years in medicine, there were only a few major hassles: insurance companies denying tests or treatments that we ordered for our patients, and hospitals pushing for early discharge before our patients were ready. There were occasional gadflies, like the encyclopedic form for the Family Medical Leave Act. Is there someone who needs pages of data for a healthy person who is appropriately driving a patient to a doctor or hospital? Most of the time, however, it was possible to reach an uneasy equilibrium with these outside influences and spend most of my time caring for patients. But no one sounded the alarm that was needed: “The stakeholders are coming.”

The word “stakeholders” has grated on me since the first time I heard it. Who are they? Definitely not doctors or patients. Insurance companies? The Federal Government? The Center for Medicare and Medicaid Services? The Office of the National Coordinator for Health Information Technology? The Center for UFO Studies? Although I’m not sure about the last one, the first four entities do qualify as “stakeholders” in that they assert control over the practice of medicine and pursue their own interests.

The most intrusive intervention that stakeholders have coerced physicians to adopt is the electronic health record (EHR). The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 mandated the use of EHR, with incentive payments for participation, and significant penalties for non-compliance. Now, most physicians would enthusiastically adopt an EHR that reduces costs, increases efficiency, and is user-friendly. Most EHRs on the market today, however, are the opposite: expensive, time-consuming, and clunky.

Have you noticed that when you see a doctor, he or she looks at the screen more than at you? Many physicians now spend more time meeting the demands of their EHR and less time interacting with their patients, sacrificing eye contact, body language, and other important cues. In addition, using EHR takes significantly more time. In our system, each click is followed by a one- to three-second pause. If you multiply that by hundreds of clicks per day…let’s not go there. And, if all of the fields on the EHR are not filled in, the note cannot be completed; but putting it off risks the quicksand of continual charting. An alternative strategy is writing scantier notes, but that’s difficult and often inappropriate when patients are more complex and on greater numbers of medications. It is not uncommon to see patients with more than 20 diagnoses and taking more than 20 medications. Of course, there are benefits to EHR: notes are legible, prescriptions are accurate, drug interactions are much less likely, and charts are not misfiled. But many physicians are feeling more and more like data entry technicians, clearly not the job description that we had in mind when we went to medical school.

What EHRs lack in efficiency, they make up in cost. In order to afford them, many physician practices have replaced transcriptionists, who would proofread and edit the dictations, with voice-recognition software. Transcriptionists can actually think. The voice-recognition programs have improved to the point where they always use real words – just not the correct ones. When I dictated, “The pain started after an argument with her husband,” it came out as “The pain started after an argument with her has-been.” (Do you think he knows it yet?) “I advised the patient to take Prilosec once a day,” came out as “I advised the patient to have sex once a day.” (Maybe the husband in the first example needed this prescription.) “She changed her diet to include thicker foods,” ended up as “She changed her diet to include rectal fluids.” (Now that’s a novel prescription for weight loss.) Detailed proofreading and editing, which are absolutely essential to prevent this sort of thing, must be added to our data entry tasks.

Extravagant claims have been made for EHR. It will improve patient safety, quality of medical care, and efficiency. It will collect and analyze data on populations, improve public health, and promote coordination of care across various specialties. Regarding the latter, picking up the phone and calling your colleague still works better. Also, coordination of care via EHRs might be possible if the various EHRs could communicate with each other, but they cannot. Alas, they don’t speak the same language. Our offices can’t use the same system as do the local hospitals, as their EHR is not well developed for our specialty. Therefore, when the hospitals need to fax us records on our patients, there is no alternative to our printing their records and scanning them into our EHR. Inefficient, and so much for saving trees.

The name of the EHR that our hospitals use is a synonym for “colossal.” Colossal is an apt word to describe the amount of paper that their faxes generate. Recently I received 300 pages for a six-day hospitalization for one patient. This tome included 12 copies of a dictated history and physical, and 21 copies of a past medical, family, and social history embedded in the EHR and copied into notes from several physicians. After reviewing this agglomeration of irrelevancy, I realized that the CT scan and MRI reports, the items most critical to the patient’s ongoing care, were missing. The temptation to pitch the whole mess was great, but the conscientious physician slogs through it.

Reports generated by these EHRs reveal the absurdity of breaking down the daily practice of medicine into its component parts. Everyone agrees that a lab report should contain some basic information so that the doctor can accurately interpret the results. The EHR-generated lab reports we receive from hospitals contain all that and much more, so that one must methodically search the report for needed information. The following paragraph lists the contents of a one-and-a-half-page report of a single blood test result. WARNING: reading it could cause a pounding, splitting, or throbbing headache.

For a single blood test, the report contains: the specimen type; date and time of collection; test and result; name on specimen; test name and order number for category of lab and collection information; test name and order number for category of order result report; name of person reviewing result with date and time; date and time of result; result status (final or not), whether result has been reviewed; name of patient, medical record number, date of birth, age, sex, in-patient unit; account number; admission complaint; number of tests ordered; specimen type; date ordered; questions or comments on order; date and time of collection; name of lab; priority; completion status; name of lab; date and time of order; name and department of ordering professional; specimen type; date and time of collection; most recent height, weight, and temperature; patient name, medical record number, date of birth, encounter date; and date and time of printing of report. (Author’s note: Duplicate items are included).

When several tests are ordered at the same time on the same patient, all of the above is repeated each time. If you need to take two aspirin and continue reading in the morning, I understand.

All encounters between a physician and a patient must have at least one diagnosis code and one procedure code. Stakeholders – in this case government agencies, insurance companies, and EHR vendors — have been salivating over the new series of codes for diagnoses, called ICD-10, which was originally scheduled to be implemented in October 2014. There is room for improvement, as the present ICD-9 has no codes for some conditions and only very general codes for others, but ICD-10 increases the number of choices from 13,000 to 68,000. And, the costs of implementing these choices are staggering: estimates in 2014 ranged from $57,000 to $226,000 for a small practice; $213,000 to $825,000 for a medium-sized practice; and $2-8 million for a mega-hospital system. More recent estimates are lower, but the costs will remain considerable and will not be known until after implementation. These estimates do not include expenses for training, loss of doctors’ productivity, or delays in payment of claims by insurance companies or governments. Stakeholders say that ICD-10 will benefit everyone. Stakeholders will benefit by denying claims or delaying payment while premiums continue to roll in. Patients will benefit by reduced spending on health care: they will have to wait longer to get an appointment, because doctors will be too busy to see them. Doctors will benefit by having a separate ICD-10 code for a patient having been struck by a turkey vs. having been pecked by a turkey.

There are other interesting and unusual codes, such as headache associated with sexual activity. I always thought headache was an excuse to postpone sex. If the patient mentioned above who was advised to have sex once a day also took Prilosec as intended, this code might apply to him, since Prilosec can cause headaches! Some other useful ICD-10 codes:

  • Struck by a duck
  • Walked into lamppost
  • Stabbed while crocheting
  • Burn due to water-skis on fire
  • Spacecraft crash injuring occupant
  • Asphyxiation due to being trapped in discarded refrigerator, accidental

I have verified all of these on my EHR. The stakeholders suffered a setback when the start date for ICD-10 had been delayed to October 2015, but they undoubtedly prepared for that date. We can expect reams of denial letters from insurance companies along with sanctimonious statements like “Oh, doctor, if only you would use the correct code, we would be glad to help you,” the correct code being whatever they say it is.

Stakeholders have an uncanny ability to turn good into bad. Most EHRs have a “patient portal” through which a patient can communicate with his or her physician securely by email. A good thing. But government regulators had to set standards for EHR use, called “meaningful use” – quickly dubbed “meaningless use” by many. It has been decided that at least 5% of each physician’s patients must use the portal each quarter. I have heard of patients being asked repeatedly to use the portal to say how they are doing after a procedure or to discuss the weather. This is what you want your highly trained doctor spending time on?

There are additional stakeholders in the mix. The number of hospital administrators has increased by 3,000 percent in the last 30 years by one estimate, and since hospital administrators control the finances, they command the highest salaries. Although they control the medical practices that the hospitals have purchased, they would never tell a doctor how much time to spend with a patient, right? Oh yes, they already do that. But they would never make clinical decisions. Right?

As for medications, remember the good old days of say, before 2011? Insurance companies covered almost all medications at an affordable rate. Now, not a day goes by that I do not have a patient tell me that they did not fill their prescription because of cost. Many of these too-expensive medications are generics! My father used to say that insurance companies are in business not to make payouts. I guess health insurance companies are in business not to cover medications.

As for me, I am determined to persevere and to continue practicing medicine, a profession I love, despite all these “improvements.” I will protest when possible; to paraphrase the ending of 1984, I will NOT love Big Brother before they make me retire. My best hope is that Apple, Microsoft, or Google will develop an EHR that is intuitive and increases rather than decreases efficiency. That would be a stake worth holding.

david m novickDavid M. Novick is a gastroenterologist with interests in liver diseases and addiction. In 2014, he was selected for the inaugural group of Fellows in the American Association for the Study of Liver Diseases. He has 70 medical publications. Recently, Dr. Novick has been pursuing creative non-fiction and humor writing. His essay, Rose, the Tarantula, received honorable mention in the 2014 Erma Bombeck Writing Competition. He is working on a book about gastroenterology for the public, provisionally titled Know Before You Go.  He and his wife have four adult daughters who have their own health insurance. Website:

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