EPISODE 12: The Killer Computers Are Coming!- EHRs with Michelle Flemmings MD, FACEP

Today’s guest is Michelle Flemmings MD, FACEP! Listen in as she shares her years of experience as a clinician, EHR expert, administrator and much more! Michelle discusses the EHR as it relates to burnout and communication as a whole.

Today’s Guest

Michelle Flemmings MD, FACEP

Dr. Flemmings is an experienced emergency medicine doctor having worked in the field for 30 years. She currently practices at a small critical access hospital where she also serves as the Chief Medical Informatics Officer, EMS and fire medical director and Regional Medical Director for EMS.

Michelle also serves as a emergency department workflow efficiency consultant as it regards to the electronic medical record in her role as Chief Medical Informatics officer.

She has oversight of electronic health record utilization and optimization of provider workflow to increase user efficiency of patient care through ongoing coordination of efforts with IT, informatics and HIM.

Email: innerdiva@me.com
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Key Takeaways

• Michelle discusses life in a critical access hospital and her journey.
• Dr. Flemmings reports that the EHR was built by non-clinicians.
• She shares the shocking statistic that 65% of an emergency physician’s time is with a computer.
• Michelle talks about how the EHR is essentially a billing platform and not built on how physicians think.
• She shares her work as an efficiency consultant.
• Dr Flemmings also speaks about how burnout is literally killing our physicians every day.

“Patient care requires physicians, we cannot be replaced by computers and computer software. There is nothing that is ever going to replace the human touch in medicine”

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Transcript

Andrew Tisser 0:11
How does the electronic medical record contribute to job dissatisfaction among physicians and non physicians alike? How do we increase our efficiency with the EHR? And give ourselves more time to spend with our patients? Learn the answers to these questions and many more on this episode of the Talk2MeDoc podcast.

[INTRO]

Hey guys, this is Andrew. Welcome back to the Talk2meDoc podcast. If this is your first time here, welcome. Don’t forget to subscribe, because today we’re going to have a great day. Like always talking to us about all different types of issues within healthcare, communication, job satisfaction and how we can fix them.

If you’ve been here before, thanks so much again. Today’s episode featuring Dr. Michelle Flemmings. Dr. Flemmings is an experienced emergency medicine doctor having worked in the field for 30 years. She currently practices at a small critical access hospital where she also serves as the chief medical informatics officer, EMS and fire medical director and Regional Medical Director for EMS. Michelle also serves as a emergency department workflow efficiency consultant as it regards to the electronic medical record.

In her role as Chief Medical Informatics officer. She has oversight of electronic health record utilization and optimization of provider workflow to increase user efficiency of patient care through ongoing coordination of efforts with it, informatics And Hmm. Well, without further ado, let’s get Dr. Flemmings onto the show. Dr. Michelle Flemmings Welcome to the Talk2MeDoc Podcast!

Michelle Flemmings 2:10
Thank you, Andrew, this is such a pleasure. I am excited to be here. excited to meet you.

Andrew Tisser 2:16
Yeah. Great to have you here. I’ve recorded a little bio about you for the listeners that you provided, but in your own words, can you just tell us who you are, what you do and your role in healthcare?

Michelle Flemmings 2:31
Well, my name is Michelle Flemmings and I’m an ER doc, having taken the long pathway. I initially thought that I was going to be a general surgeon, and soon after getting into the acting internship as a medical student, I thought, now this just doesn’t quite fit my persona.

And with time running short to the match, I decided heck with it, I will go into internal medicine. I will be Marcus Welby, and I’m going to have a blast and hang out in upstate New York see my patients have them thrive and thrive along with them. After about two years, I ended up in New York City. And this is let’s see, somewhere between 86 and 89. I decided no, I needed to pay off my student loans and I really hated my beeper.

I stayed additional time helping out some dots who had really ridiculously long hospitalization times. So I guess you can say that I was a hospitalist before the word even existed. I was happiest in the ICU. And I took on some shifts in the emergency department so that I could pay off my student loan more quickly. And granted Back then, I went to upstate, what is it called now State University of Syracuse for med school, and back then it was something like $3,000 a year and maybe 6000.

When I finished it wasn’t a heck of a lot of money, but it was a lot of money for me and for parents that unfortunately really didn’t have a lot and all the debt was on me. So I was really inspired to go and work in the EDI and cut down my debt quickly. What I didn’t anticipate is that I was going to love the lifestyle of the emergency department. The need to decide quickly the need to act promptly action, I guess what’s something that had eluded me in internal medicine because that runs much more slowly, especially in the ICU. It runs much more slowly. But gradually, I decided, you know, I still hate my beeper

. I love my ICU and I enjoyed my mentor. But in looking for other Ed jobs after that location decided they wanted to go do a residency and seem to be giving me all the night shifts, all the holidays, all the weekends and all the undesirable shifts. I said, you know, it’s time to find another job. At that time, I missed the grandfathering and ended up doing a second residency in emergency medicine at The Ohio State University and have been an ER doc now board certified since 97. So I’m one of the crazies that went back and did a second hold residency.

That is my special crazy. Yeah. And so I’ve done academics. I was an attending at Ohio State, and I was an attending a doctor’s hospital, a do program there. Afterwards, I ended up with a group that was then called EMP. It’s now a different group. I worked with them for 13 years. And when they didn’t have an opportunity in Colorado, but we saw an opportunity to move out to southwest Colorado, my husband and I jumped at it. We’ve been out here now a decade and we’re loving it.

I’m working at a little critical access hospital. And by little, I mean I can stand in the hallway, I can see all of my inpatient rooms and I can see all of my Ed rooms. Wow, we’ve expanded Oh, yeah, we’ve expanded man. We had a grand expansion. We went from four and a half beds in the ed to seven and you would think that we are You would think that we put on a new wing, we have a rural health care clinic associated with the hospital. And we’ve expanded though seriously expanded to put in an oncology Center, which saves patients from having to go over mountain passes to go and get their chemotherapy done.

Our closest higher level of care were a expanded scope level for trauma center. So there’s a lot that we can’t take care of, I have a surgeon 10 days a month, I have a crna, who is available in 30 minutes, so you got to bring your skills. Our closest higher level is a level three and that is an hour by ground our highest level one is actually in Albuquerque, New Mexico, which is either four hours by ground or about an hour and a half by air, or up in Denver. actually not true. We’ve changed that now in Colorado Springs, but then also in Denver, which are either five or six hours by ground in about an hour and a half by air as well.

Michelle Flemmings 6:58
You know, what caused you to be late to work? Well, I was stuck in a herd of elk. That’s a valid excuse. What else caused a friend of mine called me one day and says, I’m going to be late for my shift. I’m like, are you okay? Are the kids okay? Yeah, there’s just a bear in the garage. I’m gonna wait until he goes like okay. Yeah, so I’ve done the whole gambit. I’m now an ED attending here. And pagosa Springs, Colorado.

We’re down in the south corner of Colorado, closer to Santa Fe than we are to anything of size in the state of Colorado. And as a critical access hospital, we wear many hats. So I’m everything from Ed attending to Ms. Medical Director. I’m Medical Director for our 911 dispatch on the fire department. I’m the Regional Medical Director for the five counties in this quadrant of the state as well as the senior Io for a hospital which entails me being in charge of physician and end user satisfaction with use of the EHR.

Andrew Tisser 8:09
Oh boy.

Michelle Flemmings 8:10
Yeah, it’s an interesting job. Most times, it’s a blast. Sometimes it’s just thankless. But I love the challenge. I really love the challenge.

Andrew Tisser 8:22
Well, you know, I hear a lot from Doc’s that the EHR is a major source of dissatisfaction in their career. Have you run into that yourself?

Michelle Flemmings 8:33
Oh, wow. Yes, I was actually very much in that bucket myself. I remember with great joy, the days of the triplicate sheet, the one that was the ED sheet, it ran everywhere from the very beginning of triage to consultants writing on the sheet. I also though remember, unfortunately, getting pulled into some lawsuits because of those sheets because my signature and name were the only ones that were legible. So I’ve ended up being deposed sometimes for hours in order to clarify what had gone on with a case that had little or nothing to do with me. Because they couldn’t figure out who the other signatures were or who the other Doc’s were.

Andrew Tisser 9:13
Thank God, normal for a doctor to have a legible signature, though, so Oh, gosh,

Michelle Flemmings 9:18
no, you’ve seen that meme now on er Doc’s on the Facebook page, a great doctor once wrote, and then the scribble underneath it. Oh, yeah. My signature is still stinks. Jayco. When I was at a Jayco hospital, they looked at me and says, you know, your documentation is fantastic, but we cannot read your signature. And I’m like, Dude, that part’s really not necessary. You don’t have to be able to read my signature.

Andrew Tisser 9:50
So So yeah, but back to the EHR. I think that’s a pretty interesting topic. So what what have you learned in your role as CMIO.

Michelle Flemmings 10:00
I have learned that we as Doc’s are being very resilient in spite of the fact that the EHR CPOE, ie, MIPS, all of this MACRA. All of them have come down around our ears, and have tried to change the way that we practice change how we practice, we have are very resilient, we have stood steadfast, I think that some of our organizations can do more to help us stand up. And to be more involved in how these vendors put together these platforms.

A lot of them as long as I’ve been doing this, I’ve worked with a couple of the vendors so far and a lot of it unfortunately, is put together by folks who have little or no clinical knowledge. So that is reflected in the erratic workflow that they then teach us when they’re introducing and implementing prior to go live. What I love to do, and I guess it’s maybe I’m an EHR hack. Maybe that’s it, but I’m into ED workflow efficiency.

And that efficiency does include the actual end users, nurses, doctors, consultants, whoever in that EHR, because what it still needs to be, it still needs to be all about the patient, the patient needs to be back in the center of care in the center of what we do. And unfortunately, the studies show that up to 65% of the time, but an ED doc spends in the emergency department on shift is spent at the keyboard with a computer, sometimes making up new words, sometimes threatening the computer and sometimes maybe even you know, putting a hole in the wall.

But that can’t be, it should be exactly the opposite. It’s even better. What I would love is I would love it to be 15% of our time was spent with the EHR, and the rest was back with the patient. Because that’s what it’s about. That’s why we all went into medicine. It was about the patients to do better to make them better to prevent disease, to help little kids heal to help elders. Make it through being geriatric and being geriatric in a fantastic fashion.

Michelle Flemmings 12:05
Now, no, you are disruptive.

Andrew Tisser 12:09
How do we do that? How do we get to 15%? How do we get to 30%?

Michelle Flemmings 12:14
I think we need more folks like us or Ed Dobbs, especially but more physicians in general involved in the first letter of code that gets written for these platforms, the platforms themselves, if you look at it, and I’m being very frank here, almost all of them are feeding the ref cycle. Secondarily, they’re trying to say that they’re feeding patient safety.

There is an element of patient safety, I’ll give them that legibility of the chart. absolutely key the ability to share information across multiple providers at the same time, be in the same chapter of the same book, know that that patient just recently had a cat and that one today is unnecessary, or know that their echo shows an F of 20 percent from an outside facility so you don’t load them up with fluids and maybe go a different route to resuscitate them.

All that’s absolutely necessary. And yes, that does feed to patient safety, barcode scanning in the nursing workflow, blood bank bridge, making sure it’s the right unit for the right patient, the right indication all of that, that’s very important. But at the bottom line of all of this, all of this CPE, all of these charges, all the ICD 10 codes that we drop all of that the EMR levels, the ESA levels, rather that the nurses put in, all of that eventually falls to billing and coding.

Andrew Tisser 13:39
I’ve heard it what argue that is EHR as our billing platforms with a little patient care sprinkled in.

Michelle Flemmings 13:46
And I think as physicians, if we could get there in the very beginning, we could be in there in those boardrooms where they’re discussing their next iteration of whatever they want to call their new platform. I think that we can definitely get A toehold and from there a foothold and change the direction it needs to be that these platforms integrate and work well, with the documentation software. There’s no reason that I should be putting in 1979 and I look up at my documentation and it’s Roman numerals that shouldn’t happen.

Andrew Tisser 14:20
It’s ridiculous. We, my facility just went live in a new on a new unnamed one of the Giants, eh, ours as of February 1, and people quit. And this is there were people crying and, you know, there was a an ICU nurse that was yelling at the CEO of the hospital because she just wanted to give blood to a critical patient but couldn’t figure out how to do it. I mean, is and this is something we’ve been preparing for for like a year, you know, and then and then they told us after it all went you know, now that we’re a few weeks in that We did a great job. Then we were one of the best go lives…

Michelle Flemmings 15:05
Well, it’s interesting success is in the eye of the beholder.

Michelle Flemmings 15:10
I’ve I’ve gone to some GO lives and what I think is the coolest part of my job, even though from a critical access hospital, I work very closely with our particular EHR vendor, and have been working as a physician advocate. In that role, what worried me is that they were going to require of me to say great things about the EHR, no matter what, what I have in my agreement with them is that I will tell the truth.

I will say where the where the toad has, you know, warts on it, I will say where it really sucks, I will say where I have threatened the computer or wanted to rip it out of the wall and throw it in the ambulance Bay and then run it over or you know, maybe use it for skeet shooting practice. This is Colorado. But what I’ve gotten in return, thankfully, is I’ve got an inroad. With regard to how to make the workflows within that platform better, how to make them more intuitive for how a physician thinks, we have been taught from day one medical school that we go through, and we basically are putting together a soap note in our heads.

A lot of the EHR, start backwards from that and really wants you to start with orders and then go backwards and do all your documentation stuff, and then maybe go and review the chart here and there. I’ve gotten them to see that it makes sense to go back to the old way that we used to do it and do it starting with the patients starting with our findings and then branching out from there as opposed to just kind of throwing it all up a wall and see what sticks. Other things that had it’s allowed me to do is to participate in some of the initial teaching and training of physicians.

I speak fluent emergency medicine. I’ve been at this now for 30 years. I also speak pretty darn good EHR, the one that I’m using now I’ve used off and on for at least 50 15 years, the first iteration really kind of sucked. This one now still has some some problems and some challenges, but I’m able to help them to see how to best fix those so that they do not piss off the docks and so that they do get buy in and that they do get people saying, yes, this does make sense as opposed to not using it or using it improperly, or God forbid, having others user who have little or no medical training and putting in incorrect data, and incorrect documentation. So I like I love love go lives I wish we had met before.

I’d love to have come back out there to come and do a go live. If you I’ve been asked by some of the people where I’ve gone to demos to speak with them about it when I speak with the dogs that after they’ve decided to go with this vendor. They’ve been like, okay, so can you bring the shell too, because we want her here. And I sit with them and I talk them through the workflow and I’ll even do things like that. Make order sets for them that are now their favorites.

So an ED chest pain or an ED abdominal pain for Dr. Allen goes with how he thinks goes with 90% of what he typically orders on those patients, as opposed to mine, that out here in Colorado, we have all these people who travel. And on day three, if it’s chest pain and shortness of breath, it’s going to be a PE, or it’s going to be high altitude sickness. So my order reflects that. Those are the things that I enjoy doing.

Andrew Tisser 18:29
Well, I mean, it’s great that we have a physician champion out there to help us with these things. I mean, you know, this show primarily is about communication. But I would argue that the EHR is such an important roadblock to proper communication, whether that be with the patient or with each other, that talking about the EHR on the show is vastly important.

Michelle Flemmings 18:54
Oh, I love talking about the EHR, I firmly believe and I’ve seen it over my years in emergency medicine and just in medicine in general, I missed the hallway talks. I missed the, you know, Lindsey, he was one of our great cardiologists down in North Carolina. Hey, Lindsay do not for nothing but I have this patient in the Ed, this is what I’ve done so far. What else do you think? I’m going to send them up to Norfolk?

I don’t think we can be served here. He’s like, No, no, no, I’ll come down. Let’s get an echo and see what we can do. Maybe there’s stuff we can do here. I missed that collegial interaction. I know that I’m one of the last people actually, I think only myself and my husband are the only ones in our hospital who have ever sat no Doc’s lounge, a Doc’s lounge was not only a great place to get away, but it was a great place to sit down and then brainstorm.

You have a patient who’s sick as hell going from the ICU into the or what better place to sit down and actually just thought download with the other Doc’s that are going to be involved in this patient’s care. And not only think about what are going to be the challenges in the ER, but immediately thereafter. In the pack you What are we going to need to expect and anticipate in post ups day one, two and three as he gets resuscitated under my care in the ICU, or comes back through the emergency department with an unanticipated return. All of those things All that’s

Andrew Tisser 20:16
missing, remember being a medical student at a hospital that was kind of old school, and they still had like, an old style lounge, and the doctors would sit around and talk over patients and I’ve never seen that since. Never again. I don’t know. I don’t even know what a doctors Lounge is anymore.

Michelle Flemmings 20:34
It’s, it’s something that it’s funny because I turned around to my husband and I said to him, I said, Where in the world at the docks lounge go. And it was very imperceptibly done. It was very subtle, all of a sudden, it was something else and I don’t even know which room it is. Now I have a feeling it’s one of the multiple offices in our building. But that little, you know, nine by nine room with a teeny weeny refrigerator and you know some more Oreo cookies and Doritos was invaluable.

We didn’t realize that it led to the exchange of ideas, we could share pH I behind closed doors and not have to worry about it being in the hallway or in the nurse’s station and people hearing it. But I do know that the EHR has destroyed that portion of the team. It has also altered the way in which we do rounds in the morning, we have a very small hospital as I was saying, and what I will sometimes do if I’m doing a day shift is I will round with the hospitalist that now occurs over a piece of paper in their office. It’s no longer both of us going to the bedside with some nurses and the social services and whoever else is necessary.

It’s no longer the nurse and the doc standing in the hallway and starting to talk about the patient than everybody going in to see the patient and assess for the day. We’ve lost that in the end. I know some of the nurses that have come to us recently from bigger places are shocked when during a recess cetacean I say Okay, guys, I’ve done this, this, this and this. This is where I’m going next, anybody with any ideas, they are shocked and amazed that I actually include them still as part of the care team. But that’s how I roll.

That’s how I was raised in emergency medicine. It’s not all about me, that’s, that’s why we’re not left unsupervised in the emergency department is dots, we still need to talk to each other CPOE he is attempting to take that away and take away the knowledge that we can get from speaking with our nurses, you know, do you think this pain med is should be a tour at all? Or do you think this pain med needs to be more like a dilaudid? You’re spending more time in there because I’m sitting in here trying to convince this computer that, you know, I need to do X, Y and Z and it’s not behaving? What do you think? They love that. And I think that that needs to come back as well.

Andrew Tisser 22:49
We had a technical difficulty. There’s getting right back to it.

Michelle Flemmings 22:54
Oh, I’m here. I have a feeling it’s on my side. Again. We’re rural. I’m living in The southern extent of the San Juan mountains. Most of this is wilderness. So it could be on my end that somebody shot the box that the internet service comes from?

Andrew Tisser 23:11
Well, I think they were talking about the loss of the team, and you were telling us how you how rounding changed.

Michelle Flemmings 23:18
Yeah, rounding change. And then the shame of it is, is in addition to losing a lot of our discourse and discussion that we have with our nurses, because now we’re putting in orders with the assumption that they’re going to see them and act upon them. We’re no longer necessarily talking with them about what else needs to be discussed. Did that work for the patient? Is there some other thing that the patient has told you that’s necessary for us?

I had one nurse come back with a patient who had all of a sudden told her that the reason she came to the emergency department for her umpteenth visit for for abdominal pain is actually that unfortunate that she’s she was a victim of domestic violence. So it That point, that nugget would have otherwise have been lost. My nurse not discussed it with me and the patient had enough confidence in the nurse to tell her that while they were taking a stroll to the restroom to go get a urine sample, we were able to apprehend the assailant, the reported assailant, but even more so though I think that patients are starving for the physicians attention.

Literally, if we’re spending 65% of time with our EHR, the studies show that 15% of the time that we say that we’re giving patient care time is devoted to looking through the EHR, at the medical records, hunting down labs, double looking double checking our documentation to make certain that it makes sense and doesn’t say something about if you don’t feel better follow up with the coroner as opposed to going to the cardiologist spending a lot of time double checking and surveilling a system that is supposed to help us but a lot of times, unfortunately. hamstrings and shoots us in the foot, we need to get back to the point where the patient is at the center of what we do, and that we have our time.

That’s what I love about what I do. My Side gig is the EHR and EDI efficiency consulting. And what gives me joy is using the data that comes from the back end of the EHR, those end user analytics, those behavioral analytics so that I can see that my doc over in the clinic is spending an extra 40 minutes a day documenting on average, seven days a week, even though he only works four days a week. He’s spending all that extra time and devoting it to documentation in a system that’s obviously not working for him for some reason. I take the data, I crunch it down and I realize wow, he’s tab hopping a lot.

So that means that he doesn’t have a workflow that allows him to efficiently go back, review the patient chart review the labs review any outside messages or information and data that he needs to make the right decisions for his patients. How I approached him as I’m like, dude, listen, not for nothing. I know that people hate this, and they think that big brother is watching. But thankfully, big brother is giving us useful information about you. How would it be if I could give you back 45 minutes of your day, every day so you can get out on time, so that you could spend that time instead of with this EHR, trying to tell it what to do and, or you trying to assimilate with it and just say, what the hell?

I’m done? What if I gave you back bath time with your kids or storytime tucking them in family dinner? How would that feel? I love giving people back their family time, their free time, their meet time. That’s important. We’ve lost a lot of that with babysitting these systems. And that’s why being involved from the very beginning to formulate a platform to write the code to write order sets. That makes sense.

It makes me crazy that each time we do an implementation, even under the same vendor, it’s not Not like all of a sudden zosyn has become PIP facilities Oh back tam 3.375 grams IV QA. It’s not like that’s a new thing. Why are they going back and rewriting the code it seems for each different install and implementation. It should be that it comes as a preset of say 75% of stuff because about 75% of the stuff that we do throughout the hospital is exactly the same.

I don’t need the cardiothoracic portion of the platform. So leave that out. What I do need though, is I need more heft. And my geriatrics. Our county has about 18 to 22%. Depending on which study you look at, of patients over the age of 65. I need that beefed up. Let’s work on that the other stuff should come done. There shouldn’t be a whole lot of heavy lifting either for the vendor, or for us when it comes to the build and the implementation. We don’t need to be as a little hospital spending a huge number of FTS To rebuild something that should come already open and ready for plug and play. I also don’t get that why does it take a year to implement a system?

It’s not like it’s the first time you’re doing it. And it’s not the first time you’re doing it for a giant University Center. So I don’t get that. But I guess that’s some of how we end up paying bazillions of dollars for these systems. the shame of it is, is there’s nothing more expensive than a cheap tool. My dad used to say that. And if you go cheap on some Yeah, that’s true, and especially with an EHR, cheap is a relative number. But what these things cost is enough to cause a hospital to go under.

And especially when you’re talking the little guys, the critical access hospitals, the little community hospitals, there needs to be a way of convincing the vendors to give an offering that is at a price point that is not going to decimate the financial bottom line of that hospital and let it continue to serve patients. But also To end up with a product that serves their needs, who they are, where they are, what they are, and what they want to be and what they have in their strategic plan for six months, a year, three years, 510 years down the pipe. That’s what needs to be done.

Andrew Tisser 29:16
Yeah. And look at all looking around a lot of the positions that you hear from say that the HR is one of the number one causes of burnout and and young and old positions alike. I mean, it’s interesting because I, I grew up with it, right. I mean, I, I pretty much had an electronic record throughout my training and so to some of my colleagues, but we’re still just as frustrated with it. Even compared to the people that went from paper to EHR, and it’s still a major issue. And I I believe it is contributing to some of our early career physicians leaving medicine,

Michelle Flemmings 29:55
which is just it’s it’s disheartening and terror Fine all at the same time. I am a senior physician, I guess you would say I’m going to be 60 in July and I still don’t know where all the time when but I’ve been a physician more than half my life. I am not very computer savvy. I’ve been forced to become tune tutor savvy secondary to the EHR and because of my position as a CMO, we are not doing well enough our physician organizations a set a bam, a cop all of them.

We need to also pay attention to all of these studies about burnout and how it’s killing our physicians literally killing our physicians every day. We need to stand up for our physicians we need to say this is more than enough and not just draw a line in the sand and say, You know we are necessary to this equation. Patient Care requires physicians, we cannot be replaced by computers and computer software. There is Nothing that is ever going to replace the human touch in medicine. And if it comes to that stage, then we’re all really screwed.

Andrew Tisser 31:07
totalize It’s scary, right? I mean, people leaving in droves. dissatisfaction at an all time high and not just the four year career physicians, but people two years out of residency are leaving. And you know, well, why besides the chair what what else do you think is contributing to that from, from your perspective, having done this forever?

Michelle Flemmings 31:30
Well, I was the was one of the ones back in the day when Jayco decided that pain was going to become the fifth, fifth vital sign, railed against it. And I still remember telling my my counselor it wasn’t when I was a resident at Ohio State and she and I ended up talking about this a couple months ago. I still remember our conversation I sat across from the desk from her and I like yesterday, I said, what we’re going to do is we are going to create generations have people who are addicted to drugs?

And certainly it has become that and the horrible part about it is that we are being blamed although we were taken kicking and screaming into that discussion. with pain being the fifth vital sign I very well remember a young lady half my age looking at me and saying, I’m the patient, and you have to do what I say. I looked at her and I said, No, I think you have that backwards. I’m the physician. I’m here to give you the information. I’m here to give you the best of care possible. It but never forget. And always remember, it’s my license. And I’m going to do with it as I choose to do and I’m going to do for you the best I can in a correct and appropriate manner.

We’re not going to load you up with any payments and she’s like, well, I’m going to go ahead and I’m going to give you bad reviews. And in those days, it would reflect in your pay. It would be that your rate of pay dropped and patients would take great delight in torturing the doc and dropping They’re paid to ridiculous amounts because they didn’t like how their pain was treated or they didn’t get enough of X, Y or Z. Even in the even with patients who were coming in with serial overdoses that’s one of the other ones Unfortunately, that’s contributed to a lot of this. physicians have lost a lot of our standing and society.

At when I went into it, it was something of a leader someone you look to for advice, someone you look to with respect. A lot of it now has come to doctors make too much. They’re they’re all about themselves. We’re not driving around with Maserati’s , our pay has dropped reimbursement has dropped and continues to do so. Daily. We’re being replaced by mid level providers or being told that instead of having multiple physicians potentially in a busy Ed, you’re going to have one physician with multiple mid level providers that you’re now supervising. they’ve they’ve hamstrung us and I think with young physicians, that is something that we need to talk about early on, how do you go from being a medical student to a resident, and then into the reality of the world as it is now ever changing of the physician?

How do you hold on? How do you have me time free time? How do you keep the mindset that doesn’t make you want to beat the wall or God forbid, take your own life? I think we need to reach back and we need to reach to each side. And we need to take on the responsibility that yes, we’re there for our fellow physicians. And I don’t think we do that well enough, either. I think right now we’re all kind of suffering in our own separate silos. And ironically, the EHR has siloed physicians because now we’re dedicating time to it, one on one with the computer and the keyboard and not to each other, not to the patient, not to our care teams. We need to in essence, Bring back the philosophy and the aesthetic. That was the doctor’s lounge.

Andrew Tisser 35:06
I agree completely. And right now, my wife goes to work works all day and she doesn’t type in the room. She doesn’t do her documentation in the room, and she talks to her patients that are very complex. And then she comes home and works all night. Right? Mm hmm. And does her notes all night long, and all weekend? And how long is that sustainable?

Right? And it’s because she cares deeply about her patients, and she wants to take care of them. And they’re, they’re difficult, complex diseases. But she’s unable to do so. without, you know, worrying and having the stress of the medical record. And then, unfortunately, she takes it home, you know,

Michelle Flemmings 35:45
yeah. And then there’s the produce part two. There are a lot of metrics that hospitals utilize in order to decide how they’re going to pay you if they’re going to pay you and if you’re going to remain in their employ. And if you’re not meeting those metrics, they will We’ll send you elsewhere or they will tell you, I had a gentleman come in not too long ago into the emergency department and he had he reached his last straw.

He says, I was told today I had two options. Either I resigned, or I would be fired. And I had five minutes to decide. And his wife found him unfortunately at wit’s end, suicidal, it needs to stop, we somehow need to be able to put together a network that supports our dogs. There’s, there are a couple on Facebook that are really good. There’s an EM Doc’s page. That is there for Yes, social. But I find that it’s also good and supportive, to help out dogs who are going through a hard time, especially some of the younger ones. I’ve met, virtually, with some of the younger physicians who are just going through a hard time and they’re like, Well, how do it and in truth in the old days, much like in residency, you just put your head down and kept me Forward.

That’s not acceptable anymore. Yeah. No, no, our responsibilities have grown, the pressures on us have grown. The risks have grown and we’re being overloaded. So somehow we need to figure out, how do we fix this and I know a lot of dots will talk about going to the state and saying, you know, I’m having difficulty dealing with my life. I need help, they’ll go and talk with the, the physician societies, but there’s also a lot of distrust of that, will I get labeled with a psychiatric diagnosis and Will I lose my ability to make a living as a physician? That’s understandable.

I think that it forces and I know it forces a lot of physicians out of their community out of their, their ring of support, when they do go seek help in other cities or other states. But sometimes that’s what’s going to be necessary. Maybe what we need to do is offer some maybe some adopts who are listening to this may have coaching and or psychiatric mindset practices where they’re able to reach out and maybe offer telehealth to dots to fellow physicians, in order to give them an opportunity to share this with somebody and to figure out a way going forward, that is acceptable to them, that doesn’t stress them that doesn’t sacrifice their lives or their family lives, but still allows them to go ahead as a physician and be successful and do the best for their patients.

Andrew Tisser 38:31
I agree, man, I think we need to help each other because if the doc suffer, the whole system suffers, right? Because, you know, not from a hierarchy perspective. But I mean, we are essential to the system. And if the Doc’s are leaving because they can’t have a proper work environment, then what’s going to be left I’m just scared to see. But let’s, we’re running a little bit out of time here. So I want to shift gears just to get to know You a little bit better. Could you give the listeners a book recommendation?

Michelle Flemmings 39:06
Oh boy. My last really good book is a dog’s purpose. I’ve read that multiple times, but I’m also a dog mom. I rescue English Bulldogs and pugs. My latest is a little dude here named porterhouse and he’s adorable. Yeah, because he’s a meaty boy. He’s porterhouse, Mickey’s Big Mac, he’s adorable. I’m also the one though that adopted the pug with a lazy eye and called him Elwood notorious PG. After Biggie Smalls. That’s fantastic done. But that’s what I do in my spare time. I also am a master gardener. And that as well as quilting, I think are great just outlets for me.

In addition to travel, I love getting on a plane and waking up somewhere else and meeting new people and seeing the world from a new vantage point. All of those things I think are other things as well that we as physicians can hopefully help other dogs to do by providing them with their friends. free time and telling them that they’re not alone. Maybe we can have some meetups and some mindset sessions, instead of having all sorts of CME conferences, let’s make it more about wellness.

Sometimes do retreats meet not virtually but actually, you know, I think that’ll be a great help as well. Absolutely. As for my now book that I’m reading, I’m very proud of a friend of mine and reading her manuscript. It’s, I don’t know if the title is going to stay the same, but it’s called becoming me. And it has a lot to do with what we’re talking about, which is compassion fatigue. She did a TED talk about six months ago, and that spawned a book and hopefully it will gain traction when it comes out. But it’s real compassion. Fatigue is really you just run out. You can’t help your well is dry.

Andrew Tisser 40:47
Yeah, I’ll be sure to keep an eye out for when it comes out. I’d love to read that. And I usually ask for a piece of advice for the area of communication but given your specialty could you Give one or two actionable tips for physicians and other healthcare workers in regards to the EHR and how to make their lives a little easier.

Michelle Flemmings 41:09
Absolutely. We actually I instituted a huddle because the EHR was failing us in the ability to let us know what was available throughout the hospital. We don’t have 24/7 services, a lot of things. And that particular case it was an ultrasound that hadn’t gotten done. What we did the next day is I had them announce overhead huddle, and I asked for a representative from every department in the hospital to come to the EDI, and report as to what their capabilities were.

We started that I think four or so years ago, and people now miss the huddle when the ad is too busy for us to have a huddle. But that has gone a long way to reproducing and extending our communication all the way from inpatient straight through to the clinic, the lab and oncology clinic. That’s been great. I think it’s important with regard to the EHR, not to forget to still talk to your nurses and your team, about the patient.

I think that’s vital. As well, if you need help with your EHR, get out there. You can contact me through, do your podcast. I’m also on Facebook. I’m also on LinkedIn, where I rail a lot to the vendors about why they’re not doing better. But yeah, reach out. I’d be glad to talk with you on the phone. I can do a zoom with you and talk you through most of what ailing you so that you don’t have to make up new words and curse at the computer.

Andrew Tisser 42:34
Perfect, awesome. Michelle. For the listeners. I’ll put all the contact information in the show notes. This has been a really great conversation. I really enjoyed it, minus our little technical mishap, but we got through it.

Andrew Tisser 43:01
Wow, what a powerful episode with Dr. Flemmings which just focused on so many different aspects of medicine. I enjoyed hearing about Michelle’s journey and her life in a tiny critical access hospital. Additionally, her thoughts on job satisfaction with the EHR and how she helps physicians and nurses I like to, quote hack their way through it was very interesting. Michelle speaks about how the EHR, unfortunately was built by non clinicians and at times is in fact a billing platform.

I was saddened to hear the statistic that 65% of emergency room doctors time is spent with a computer. That’s horrible. Her mission to get time down to 15% is really a noble one, even 30% would be incredible. Michelle speaks about how EHR hours were not built based on how physicians think and I do believe this is an important problem here. As acting as a EHR and efficiency consultant, Michelle really brings value to those she serves.

Conversation then shifted to burnout both in the early career physician and the late career physician, and Michelle stated that burnout is literally killing our physicians every day. frustration with the EHR is certainly a large portion of it. And I see that myself. Dr. Flemmings does also talk about how the EHR has siloed physicians, and takes time away from spending time with patients and spending time with each other, which is a very important part of taking care of both ourselves and our patients.

Thank you again, for listening. I hope you enjoyed the first episode of our second topic area, which focuses on early career physicians and burnout as well as some of the challenges we face the EHR touches on all of our personnel within the healthcare field. So certainly a lot of you You can resonate with Dr. Flemmings’ message, please remember to subscribe to the show and mentioned me on twitter at talk to me doc. Till next time, keep talking guys.