Sink or Swim


My mom is great.

Unfortunately, like most mothers, she relishes telling funny (usually embarrassing) stories about us kids.  I, unfortunately, seem to be the subject of the vast majority of those stories.  But my big brother gets the leading role in one I will now tell.  I guess it\’s a small way to get back at him for…well, for lots of stuff.  One day he came home from school all excited (unusual for my half-vulcan brother).  \”Mom!  Mom!  I learned how to swim today!\” he said.  \”Oh?\” my mother answered, not sure how and where he learned this new skill.  Bill got a very pleased expression as he explained, \”Steven V. taught me on the bus!\”  This is where my mother guffaws and my father chuckles and we kids look at each other with the well-worn \”when will this story get old?\” expression.  He\’s probably making that expression at his computer right now.

Sorry, Bill.

But the naïveté expressed by my brother at the nature of learning how to swim is similar to my confidence going into this project.  Certainly it helps to know you can\’t breathe underwater, and that swimming in a suit of armor is a bad idea, but this knowledge does not substitute for the first-hand experience of keeping afloat while the water seems to be trying to drown you.  Similarly, I could read books, make a business plan, and impress people with my thought and insights, but that does not substitute for the first-hand experience of building a new business from scratch.  It does nothing to keep me financially afloat while unseen forces try to pull me under.


Which brings me to my current situation.  Would I have taken the plunge had I known what it\’s taken up until now?  It has been hard.

I hesitate to write about this, because:

  1. I hate to sound whiney.
  2. I don\’t want people to worry that things are worse than they are.  Especially my patients.
  3. I don\’t want to get a lot of advice from well-meaning people who don\’t know the details of my situation.

But I want to give a realistic picture of what this journey is like, not just throw you the vaporware version.  Besides, my world right now has significant stress and pressures that I didn\’t anticipate.

The first sign of trouble came very early, in the renovation of my office.  My goal was to start seeing patients in mid-December, and officially opening around the first of the year.  Unfortunately, the office wasn\’t ready until February 6th, and the construction cost twice what I expected.  For those who can\’t see the implication: I spent more money and lost a month of earning it.  More money out, less money in.  Maybe swimming\’s a little harder than Steven said it was.

Then came the EMR debacle.

Of the areas I was most sure of, my ability to use computers to improve care was at the top.  After all, I had won national awards and much acclaim for my use of electronic records to improve care.  Two months and five EMR products later, I was beginning to see just how far the health IT industry had moved away from patient care.  I din\’t know what to do; I was at an impasse.  Each system I tried either lacked some basic element of organization I required (such as management of outside documents) or was unable to generate anything but the voluminous documentation which succeeds only in two areas: getting physicians paid and hiding useful clinical information.


It was as if I was in the TJ Max dressing room, desperately trying on clothes for a formal dinner with the president.  I was looking in the wrong place for what I needed, yet I couldn\’t go naked.  So do I keep looking, hoping that something would work, fracturing the already disjointed patient records all the more?  I knew what I needed to truly give good care for my patients, yet nobody came close enough for me to be willing to overlook the deficiencies.  The alternative I was now facing was one I desperately resisted: to build my own system.  I resisted this idea because:

  1. I am a doctor, not a computer programmer.
  2. Medical records are incredibly complicated.
  3. My time was limited.  I couldn\’t spend all of my time on something that didn\’t itself generate revenue.

But in April, two moths into my practice, I dove head-first into the icy water of the enormous task of building my own record system.  Since that time I have spent (even by my own work-a-holic standards) an incredible amount of time working on the project.  Whereas in the past I\’ve been motivated by the obsessive fun of building something, this was driven by the ever-growing fear of drowning financially.  If I couldn\’t build a system on which my practice could not only work, but thrive, I would eventually be drawn down to the icy depths.

This is why my writing has dropped off over the past few months.  Every day my creative energy is sucked dry, leaving me in the evenings only enough energy to play \”bejeweled\” or watch \”Alias\” on Amazon.

Adding to the stress of creating a new record was the state of my previous medical records.  They were all over the place, stored in the 5 different systems I tried while coming to the realization that my search was futile.  Not only did I need to put these records into my new system, I had to scrounge around for them when trying to give care for my patients. Over the most recent months, my focus has been on improving the quality of care I give, rather than to grow my overall patient volume.

This, unfortunately, doesn\’t do well for my bottom-line.  It\’s hard to convince my mortgage company, the colleges three of my kids are attending this fall, and the grocery store, that money is tight and that I deserve a break.  Just as the water doesn\’t treat a non-swimmer with gentleness, the reality of finances are pulling me ever downward.


This puts me at a huge decision point: I don\’t think I can grow the business enough with just me and Jamie doing the work, yet adding people would cost money I don\’t have and delay my own salary even more.  Yet I need someone to take away the business tasks I\’ve done out of necessity (but am not good at).  Plus, we need to be working on setting up contracts with small businesses, developing the side of the business I think has the most potential.  Plus, it would be real nice to have someone else be responsible to make decisions.  I find myself even resenting having to decide what to wear, or what to have for dinner.

So I am working on getting the finances necessary to do hire a business manager (and already have someone in mind).  I feel like my efforts to build a record system that will support my business model are paying off.  There are just a few areas left to build, and I\’ve had a delightful amount of help in working on their future development. So now we need to start capitalizing on the huge amount of grease I\’ve exuded from my elbows over the past six months.

The driving force behind all of this – the thing that keeps me from giving up – is my belief in what I am doing.  I believe in this practice model.  I really feel it is a game-changer.  If it works like I think it can, it will improve the quality of care, reduce it\’s cost, and make the experience much better for both doctors and patients.  If it can work on a bigger scale (more than 1000 patients per PCP), then it is goes from good idea to a very compelling alternative to doctors, patients, employers, and insurance companies.  It could be huge.

As of now, however, I am still in the water struggling against gravity.  This is the hard time.  It\’s not easy.

Maybe I should call Steven V and see if he can tell me how it\’s done.

22 thoughts on “Sink or Swim”

  1. I believe you are the one to do it. I believe HE has chosen you for the task. My friend keep up the good job. You have a lot of people behind you that will need your experience. Paula C

  2. Databases are like hats. One size does not fit all. Especially if you have a big head. Not that you have a big head. Just saying.

  3. Lu Mueller-Kaul

    Where are you? This post makes me want to come by and talk to you. I keep working on and wondering about different business models as well… fortunately I don’t have to worry about EMR yet.I guess the problem is that good care makes no profit. So… I’ll have a meeting coming up with my therapists to explain to them why I have to find other ways.

  4. You could get help from some of the big boys like Dell, HP, Nextgen, Citrix, etc. That are all desperately trying to participate in the digital healthcare. If they can’t (actually won’t) provide devices they may provide service.Also, you mentioned growing sales – do you have a salesperson with connections to the people you want to sell to? If not, you may be disappointed in the sales progress you make. You can find other companies that have started small and grown like law/accounting/engineering firms that have similar problems as yours, Ask to go to lunch with some of the principals and they will likely help with what worked for them.
    Build your own database is time consuming and a little dangerous. The big problem you will face is when it comes time to upgrade. Eventually you’ll need to upgrade the software. When that happens you will lose you customizations. This will require staying on your unsupported system or rewriting the customizations. Be careful of this one.
    Do you have a requirements document for your medical records?
    Good luck
    Ed S

  5. Hey, Rob, bully for you! I read your piece at Dr. Kevin Pho, as well. This is a long shot: have you tried crowd-sourcing? Jumpstart?

  6. The problem with the crowd sourcing options is that they focus mostly on technology (kick starter does). I have definitely considered this option, though. It just takes a lot of work to make a pitch worth of putting out there for funding.

  7. I don’t understand how a PCP can have 1000+ patients without advanced decision support. The computer is the only master diagnostician.

  8. Dr. Rob,
    I’m an MS2 in GA, and I have been following your posts of late. My question is this: do your practice plans include trying to become an official Direct PCMH? You probably know about the rules in the PPACA that allow PCMH retainer fee models to be sold on the new exchanges in conjunction with a wrap-around, high deductible plan (in order to provide patients with innovative primary care AND access to hospital and specialty services). What is your take on this? Have you ruled this option out, or is it too early in your transition to think about this?



  9. I’ve been working toward that. This is one of the big reasons I am working on getting a business manager. The market for this is absolutely huge, and could be the thing that ushers DPC into the mainstream.

  10. Fred:I did consider this and was against the idea. It wasn’t until I tried using EMR products for more than just documentation that I realized they do little else. I hope you know that I am a 16 year EMR veteran and former Davies award-winning evangelist for improving care using EMR. I have seen EMR go from a possible tool to change care for the better and instead see it get changed for the worse. I saw only one choice: tolerate the worse patient care that EMR products enable me to do and compromise my hope to truly change care, or to (despite major misgivings) really take on the task of building something completely different. I spent the last 18 years progressively compromising to a system that pulled me away from my patients, so the decision was not difficult. I will say that the task has been incredibly hard, and if I was not quite familiar with both IT and clinical workflow redesign I would have to agree with your warning. Still, I think your warning holds true, as I would not recommend this course for others. It has been incredibly hard.
    It does seem a little odd for you to question my ethics, though. It seems like an accusation of hubris on my part, which my other writings should clearly negate. I have lived in a world where my care was limited by the blindness of software designers to the realities of the exam room, and have felt that the health IT community is guilty of causing real harm to people by making products that interfere with good care. I think I as a doctor (who understands the practice of medicine, focuses on patients, and loves and understands IT) am an ideal candidate to to something radical like this. I actually have taken significant counsel from Mark Leavitt and Blackford Middleton, to physician friends of mine (from our old MedicaLogic days) in this process. They are both physicians who looked at the problem and had the confidence to think they could do it better. They also could not give me a good product to consider as I pondered making the leap to building my own system.
    I think what I am doing is not like, as you suggest, me trying to build my own car. It’s more like a surgeon who sees how a different kind of tool could make surgery much easier and safer, who then goes to fashion a prototype to let others see what he means. There are times we must step out and challenge the mainstream. If I win on this, I believe the benefit to others could be enormous. My goal? Not to own/sell/manage an EMR product. I just needed a tool that would actually help me prove this kind of practice is a viable alternative to the bad care that is being done out there, aided by the EMR systems built to perpetuate the flaws of a system focused on everything but patients.

  11. Wow. Lots of commenters whom I’m sure are trying to help, but they sound like confidence-drainers to me. You are a pioneer. You will succeed, because you’ve already come so far and because you are obviously a driven person. I know another guy like you who set up his own lab, and he went through similar moments, but now he is successful. Keep your eye on the prize – taking the best care of patients possible and making a living while doing so. You’ll get there!

  12. Self employed people are the bravest people I know. I can’t believe you’re doctoring as well as programming an EMR. Good luck to you with it all.

  13. Sharon McCoy George MD

    Rob,Totally admire your attempt at creating an EMR. And always enjoy your sense of humor. Hang in there.
    Are you going to the Direct Primary Care Summit in St. Louis in October? (not that you are looking for another use for your time…..) Would love to meet you and share ideas about how to make this whole venture (those of us doing solo, independent direct care practices) succeed.

  14. Spoiler alert: this could be a pesky well-meaning-but-useless post. We have a small business with all the associated short-staffed, short-cashed problems. We are outsourcing our admin work to an Indian company for a fraction of the cost of hiring locally (Sydney, Australia). Let me know if you want further info.

  15. I hope you noticed that I have never actually “called you out” by name on my posts. Comments like this one make it clear that you are aware, at least in some level, that you are in an ethical dilemma. A dilemma that you are resolving differently than I would suggest. The fact that you are clearly thoughtful about this is a valid deflection of much of my criticisms. It is dreadfully difficult to frame things in an ethical manner, without seeming judgmental.
    A parallel might be someone who recognizes that eating meat is an ethical issue, while still choosing to eat meat:

    I respect your position, precisely because you seem to be so fundamentally conflicted about the matter. There is certainly space to come to different valid conclusions given the same complex ethical problem.

    Clearly, you are not guilty of hubris. Remember that you are not the first doctor that I have confronted about these issues. I am not just writing to you…

    I wonder, however, why you have not tried extending an Open Source EHR. That just seems easier than you current path….

    Lastly, I did not choose the title of the healthcareblog article and I am asking them to change it… They wanted to “juice up” the debate but I think they missed my point with that title.


  16. I have tried to not call you out either., and appreciate your restraint. Don’t worry about the THCB title, as they are in the businessnof selling eyeballs, and have renamed my posts liberally as well.
    You did hit close to home with the post, voicing a criticism I have leveled at myself. I am no longer conflicted, however, in that I do think I did all I could to keep from choosing this, the hardest path. Mark Leavitt gave good counsel on this (first advising against this route, and then after seeing my futile attempts to jury-rig a workable system from the junk out there, encouraging the jump). He has been in my position before.

    I see what I am doing as the shortest route to the goal: creating an EMR designed without the huge friction caused by the billing and coding requirements of our health care system. My vision for care moved much further from what it used to be than io ever expected, so far that even the open source software seemed to impose unnecessary burden. I wanted to draw it on a clean sheet of paper so I could discover something that had as little of the malignant influences of the payment system as possible. As I said, my ultimate intent is not to build an EMR, but to build a prototype for something totally centered on patient care, something that will allow my practice model to be easier for others to adopt. My ultimate goal is (yes, perhaps with a whif of ego, I admit) to disrupt the system with a model that is better for doctor, patient, and save money.

    But even if it doesn’t do the, I just want to give my own patients the best care I can, and this gives me the best chance to do that. I appreciate you challenging me in my thoughts and forcing me to understand my own motivations. Critics are only the enemies of despots and charlatans.

  17. Thanks. I will check out those resources. It is a hard balance to have, with part of me seeking any help in this process I can find, while another part sees the incredible effort I have put into this and doesn’t want to know about other options any more. I don’t have the luxury of trying each of these on, as my primary goal is to have a working practice in this new paradigm of care (new for me, at lest), and I have to get things to work in the little picture of things, I would be willing to show you what I have done, and perhaps your advice to me could be more granular regarding where I should move next. As you see, I try hard to not be a typical knuckle head doctor who thinks the letters after my name make me good at everything and cause me to ignore the advice of others. Yet I have to be the driver of this project at this point, as I have the unique position to know what actually helps my practice in real life and what will truly enable my vision of a that I think has the potential to be a positive disruptive force if done properly (with special emphasis on those last three words). If interested, email is rob (at) doctorlamberts (dot) org.

  18. I have formally asked them to rename my blog post… they are indeed after eyeballs but that post title makes me look like a moron. Obviously doctors will always be at the center of the EHR design and development process, no matter what approach you are taking.
    I am deeply sympathetic to your trials. You obviously would not be doing what you are doing unless you felt you had no choice. I would encourage you to look at OpenMRS. OpenMRS was designed from the ground up to be a good EHR in the international environment and as a result has not of the cruft that you are complaining about regarding US oriented “procedural and billing based design” that is so common in other EHRs. I would say look at VA VistA too, but it can be hard on beginners. (OpenMRS is Java-based, VA VistA is MUMPS based). I expect that OpenMRS would “fight you” much less as you sought to build on top of it.

    If that is not possible, then I would encourage you to make your own system as modular as possible, since this might make later integration with something else much easier. There are some projects forming to create a standardized WebRCT tele-medicine component that you might also find useful.

    Most of all I would be aware of NewCrop, which is the easiest way to do medications safely without trying to take that on by yourself. That is probably the most critical part to get right, from a safety perspective.

    I have been thinking alot about the fundamentally unfair position you are in. At least on some level, you are telling me that you have self-voiced the doubts that I have before I said anything. On the other hand, you face a market place that is so intrenched in the third party payer thinking that it just does not offer you much help. I had hope that Hello Health might have been able to offer something to your market segment, but so far I have been disappointed by their offerings too.. You are in quite a pickle and think the forces that put you there are worth fighting against… Otherwise inertia wins.

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