I am a pediatrician who trained in a residency program that taught us insurance companies were evil entities intent on profits over patient care. As ICD codes and CPT codes expanded, my colleagues complained that these were ways insurers could deny care and keep them from making a living. When electronic medical records (EMR) entered the scene, many doctors complained again about the tyranny of spending all their time typing on EMRs, not being able to make eye contact with patients, and how EMRs were another tool of enslavement to insurance companies that ate into their family time.
I want to share my story. I completed a pediatric residency program and then a fellowship in medical informatics before embarking on an unusual career that included pediatrics, government, and tech consulting, and even disaster medicine. I was a key subcontractor on the United States’ first biosurveillance system and coedited the first textbook to describe biosurveillance as a branch of data science.
In 2010, I opened a private pediatric and adolescent medicine practice in Reno, Nevada. I used an EMR from the start. I accepted any patient walking in the door, which meant I very quickly got a heavy stream of very sick and very disabled patients with complicated histories. My patients were more acutely ill than average, and many were referred to by other doctors as “train wrecks.” I had patients with asthma, severe migraine headaches, endocrine disorders, and rare diseases. I became the regional expert on young patients with abnormally low cholesterol. When pediatric ICUs across the wider region discharged patients, the intensivists called us to take over care.
My EMR became the third most important tool in my office, after my brain and my loyal, devoted staff. The EMR was more important than my stethoscope, otoscope, or ophthalmoscope. It helped me organize my thinking and spot trends in my patients. It helped me avoid mistakes. My use of the EMR never interfered with my communication with patients. I did not type while talking with parents and patients. I did use my computer to show them relevant things on the screen. My staff used the EMR to organize our vaccination effort. Parents loved the way we communicated, the way we handled emergencies, and the way we worked hand-in-glove with specialists. We handled many cases that other pediatricians would not touch.
One day, our biggest insurer (which offered both commercial insurance and Medicaid) sent a nurse and its medical director to our office. I wondered why they had come; had we done something wrong? I was in for a pleasant surprise.
They showed me and my manager that our practice was already one of the highest-performing practices in the region, with much higher-than-average outcomes than other practices despite having much sicker patients. The insurer’s nurse told us, “You can get even better.” She laid out the deal she had for us. She showed us how to use CPT codes so that what we did was more precisely and accurately reported to the insurer. She showed us how to generate reports we had not yet used. In return, the insurer gave us a free hand to run the business. I practiced medicine my way, with no interference. Our region suffers from a shortage of pediatric specialists. I handled a lot of complex problems internally without a specialist, charging higher visit codes and even overtime codes, and was paid for all of them without complaint. I successfully treated some patients with conditions that, normally, only a specialist would treat. My prescriptions, usually for generics, were rarely questioned. I worked out protocols with specialists and ordered imaging, including MRIs, CT scans, and ultrasounds, before requesting consultations. These were well organized in my EMR. I gained a much better understanding of my patients’ conditions, and the specialists made faster treatment decisions. The specialists were eager to help me because I saved them a lot of work. They taught me a great deal. They made me more effective as a pediatrician, and I helped them become more effective as well. Trust and collaboration were the norm. If a specialist refused my referral, it was because the specialist did not accept the insurance or Medicaid, not because the insurer blocked the referral.
The results? The insurer’s nurse returned periodically to our office and showed us data documenting our improvement. Our practice won awards for exceptional quality of care and community service. U.S. Senator Dean Heller read a tribute to the practice into the Congressional Record in 2016 and my medical school alma mater named me a Distinguished Alumnus in 2018. Our practice was one of only two in Northern Nevada to consistently achieve very high vaccination rates for ten years running, often reaching or exceeding 90 percent, and in 2019, the CDC and American Cancer Society recognized our achieving the highest vaccination rate in Nevada for HPV at 93 percent. In fact, our practice achieved the second-highest HPV vaccination rate in the United States. Moreover, we saved the insurer thousands of dollars in specialists’ claims while helping those specialists focus on more severe cases.
Of course, there was a personal cost. I spent long hours at the practice. Twelve-hour days were the norm and sometimes went longer. But neither the EMR nor any of the insurers caused those extra hours. They simply were required to perform the competent work that resulted in the desired outcomes. Without the EMR, I would have spent more time at work, not less.
My detailed and organized notes on the EMR brought another benefit: They prevented lawsuits and potential problems with the Nevada State Board of Medical Examiners in the rare event of a complaint. In fact, I have only been sued once in my entire career, and that lawsuit resulted in my winning a settlement for malicious prosecution.
I have had physicians tell me, “You were lucky,” and that they remained convinced that insurers are evil and EMRs the instrument of that evil. They dismissed my viewpoint as irrelevant and idiotic.
Would the benefits I saw from my EMR accrue to a practice serving patients who, by and large, are healthy and with serious illness or disability rare? When an EMR is used smartly, I cannot think of a reason they wouldn’t. This does not mean that EMRs are perfect; like any other tools, they will continue to evolve and improve, and physicians have a role to play in this evolution.
Would taking a different attitude toward insurers reduce the stress other physicians feel when billing for care? I think it could, but I will concede that not all insurers are the same.
I am certain of one thing. The closed-minded thinking I see around EMRs and insurers will help neither providers nor patients.
Ron M. Aryel is a pediatrician.
