You should know that medical documentation has gone awry. I devoted an entire chapter to this topic in Finding Truth in Transparency, but you really just have no idea. If you’ve been to the hospital or to the doctor’s office even once this year, I’m willing to bet that at least a portion of your medical information is now found somewhere within an electronic medical record (EMR). An EMR is really just some mega-computer that stores your health information. Lots of it.  And, I guarantee you that the EMR that contains your medical chart is also full of universally unhelpful medical information. It’s bloated on purpose for medical billing. I’ve used eight different ones in the last 4 years and every one has been the same in this regard. Bloated.

In fact, more than likely, your medical chart has very few informative notes in it anymore. Fragments of thought are there, pieced together by a computer template. Individual problems (a.k.a. your medical issues) are charted.  And, trust me, they are charted again and again. But, even us physicians have trouble figuring out how the charted problems in a bloated EMR intersect into legitimate diagnoses that someone is actually doing something about. The system is broken. 95% of the words in an EMR might as well be monkeys typing on a typewriter.

Despite the recent push for “electronic” (and paperless) systems, actual “paperwork” still abounds in healthcare. In fact, I’d be interested to see someone study whether or not, in the last five years, the absolute volume of medical paperwork has been reduced at all. I suspect you’d find that for every one piece of paper eliminated, three have replaced it. And, it’s not just the EMR systems that generate the paperwork.


One of my medical assistants is out on vacation today. I let the other one go early this afternoon because it’s the day before a holiday. I’m on-call this evening, so I’m not leaving town. I’ll be working a few more hours in the office, getting stuff done. Really, I’m just catching up on, you guessed it, paperwork.

A pile of mail is sitting on the desk. This is just the mail from today. I’ve already gone through a dozen envelopes. Several of these were sent to me from insurance companies. Here’s one from Cigna. You are going to love this one. Cigna uses some of the premiums that it collects from its members to distribute junk mail. Ok, so Cigna doesn’t see it as being junk mail. But, I define junk mail as being mail which takes up my time to sort through while providing limited value. You can judge for yourself.

Today, Cigna has sent me a letter on behalf of one of my patients, whom we will call Amelia. Cigna calls this type of physician letter a “Well Informed” message. Cigna uses claims data (essentially Amelia’s medical diagnoses related to services billed to her insurance company) to paint a crude picture of Amelia’s medical condition. Cigna then uses this information to make recommendations to me regarding Amelia’s care. On most days, its the equivalent of suggesting a recipe to the chef without having a clue about the ingredients actually in the kitchen.

Of course, Cigna includes a disclaimer with the letter. Cigna tells me that it is “not intended to be specific recommendations for treatment.” This is really the only part of the letter that irritates me. I just wish that we could all be transparent and tell it like it is. Do you think that Cigna is really sending me this letter for my leisure reading? Absolutely not.

Cigna wants me to know that it has identified a “gap” in Amelia’s medical care. Cigna thinks that Amelia needs to have a lipid panel obtained. “You may be aware,” the letter informs, “that ATP III guidelines from the National Cholesterol Education Program recommend that in people being treated for high cholesterol, lipoprotein profiles [this is a lipid panel] should be assessed annually.”

This statement made me chuckle. The reason that it’s so funny is that the ATP III guidelines were published in 2001 and last updated in 2004. In fact, outdated knowledge at your insurance company is so commonplace in my own experience that it ends up being one joke after another. In the spirit of education, I would have at least appreciated Cigna citing the most recent ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. This document was published last year, in 2013, making it, at the very least, within our same decade.

The lipid panel that Cigna feels Amelia needs is just a blood sample collected to evaluate your cholesterol. Cigna says that it will keep sending this letter “every 6 to 12 months” until the “identified gap has been resolved.” Cigna will also keep sending the same letter to Amelia’s primary doctor too. More junk mail for all of us.


I agree with Cigna on one account. There are lots of “gaps” with Amelia’s medical care. But, needing a lipid panel is not one of them. She actually needs assistance with keeping her appointments. Perhaps, Cigna can become involved with her transportation to and from my clinic. She also needs help remembering to take her medications. Maybe, Cigna could write her a few letters to remind her. The irony, related to Cigna’s recommendation for a lipid panel, is that Amelia isn’t even being treated with a cholesterol medicine. She is reluctant to take those pills.

I’m actually focusing on only one issue with Amelia’s health at this time. I’m doing all that I can do to assist her in stopping smoking. You know, often smothered by all of the paperwork and check-boxes of modern healthcare, is the fact that medicine is still as much of an art form as it is a science. Amelia and I have even made some headway regarding her smoking over the last two visits. It just exhausts me to think that Cigna wants me to waste my own paper and stamps to write a letter explaining all of my thought processes to them. Besides, I’ve already painfully documented every one of these details numerous times in the bloated EMR that I was required to purchase. Keep in mind, there is not even one physician at Cigna who has seen Amelia. I’m Amelia’s doctor. Why is Cigna going to keep sending me more letters about a lipid panel that Amelia doesn’t even need or wouldn’t even obtain if she did needed it?

I’m just going to throw that letter away, because there’s still so much more for me to sort through today.  For example, this other letter here is from Aetna, a second insurance company. This letter is regarding a different patient and a different blood test recommendation. For the record, I’m not even following this patient for the condition that is related to this blood test. Discard.

Here’s a letter from BlueCross BlueShield, yet another large insurance company. BlueCross BlueShield is requesting that I submit patient charts to them for review. I can either be placed on a “preferred” or “not-preferred” list of doctors based on the quality of care that they determine I’m providing from these charts. Ultimately, they intend to adjust my reimbursement based on how well that I play this game. I actually think that I’d rather just send them a copy of my book and have them read Chapter 3: The Futility of Most Healthcare Quality Measures.


Doesn’t it seem just a bit odd to you that your insurance company is guiding your medical therapies? How are these companies suddenly an unbiased third-party for making recommendations regarding your health? Does your homeowner’s insurance take it upon itself to regulate every item in your bedroom? In Aetna’s letter specifically, Aetna even claims that they have proven that these type of letters and alerts improve the care that I provide to you. I was actually chomping at the bit to see the references for these studies, because I wanted to review the sources myself. Unfortunately, Aetna didn’t provide me one. Regardless, the only thing that I know with certainty is that Aetna didn’t come to these conclusions by studying me.

You see, alerts like the kind found in these letters aren’t helpful to people like myself who are already suffering from alert fatigue. Do you know that my EMR is already setup to provide these type of alerts for Amelia and my other patients when I open their charts? I don’t need more letters from Cigna. At the hospital, every time that I order a medication to be given, an alert pops up. I literally end up having to override nearly every order that I submit. Not some orders. Essentially every order. Alert fatigue is running rampant in medicine and it’s a major reason that all of our complex systems still haven’t been able to put an end to medical errors.

Imagine setting up an audible tone that beeped every time that you walked out the garage door of your house. The purpose of this tone is to remind you to not leave the house without your wallet. In theory, it’s a great idea. You leave the house, you hear the beep, you check to make sure that you have your wallet, and then you get in your car and drive off. This might work okay for a little while. But, ultimately, if the door is constantly beeping, you will inevitably begin to ignore it. One day, your brain will ultimately block out the noise entirely. You won’t remember why it’s even beeping. And, then, there will come a time when you forget your wallet, just as you occasionally did before you installed the audible door tone.


Look, I enjoy being a physician, but afternoons like this are not enjoyable. Just going through the mail is a microcosm of the larger problems within our United States healthcare delivery system. If I didn’t believe that the system was fixable, trust me, I would have already thrown in the towel. But, I’m not ready to give up on things yet. In fact, I’ve just begun to talk louder. However, it’s time for the people who make the rules to listen, and the people that vote for them are going to have to do the same.

Have you seen the magazine in your airline seat pocket recently? It’s filled with advertisements encouraging you to fly across borders to get your medical procedures performed. The ads are there because people are doing it. Middle-class citizens are starting to outsource their healthcare because our system is failing us. I don’t know about you, but as an American myself, I find that embarrassing. It’s time to move the target closer and begin fixing a few of the easier things.

1. Leave the doctoring to the doctors. Your insurance company should not be involved in making recommendations to physicians regarding your medical care. Do you think that your auto insurer is constantly providing tips to your mechanic on how to fix your damaged car? Let’s all do what we trained to do, and I am your physician.

2. Incentivize the right people. You and your insurance company have your own relationship. At the fundamental level, your insurance company has certain terms, and you have agreed to follow them. We’ve gotten this concept all twisted up in recent years, so I’ll straighten it out for you. Your insurance company should be incentivizing you to be healthy–not incentivizing me to make you healthy. Read that again. Your auto insurance company gives you a discount for not having any accidents last year. Your homeowner’s insurance cuts you a deal if you have a home security system. If they really want, let your health insurer do something similar.

For example, if BlueCross BlueShield strongly believes that you stopping smoking will cut your healthcare costs (and therefore make them more money), then let them come up with whatever incentive-based plan that they want to offer you to help you get off the cigarettes. If Cigna wants to lower your annual premium by 3% by having you obtain a yearly lipid panel, fantastic. In fact, have your insurer submit to you all the “health incentives” that they want you to meet. Then, you will be motivated to go find a phenomenal doctor who will help you obtain your “cash back.” This is essentially how businessmen and businesswomen drive quality in America. When everyone suddenly becomes in search of anything and everything that provides value, quality begins to take care of itself.

3. Consolidate the alerts. If you have already done number 1, then number 3 is already halfway there. And, if nothing else, we’ve at least gotten rid of the junk mail alerts from the insurance companies. Ultimately, physician alerts should only come from the individual EMR systems where all the patient data is getting stored anyway. In general, these systems remain a mess, and my suspicion is that we are still a decade away from having a truly integrated EMR interface. But, that has got to be our goal. It is our only chance for healthcare survival.

Imagine coming to see me in my office. You’ve lived in three states over the last five years. You had laboratory blood work obtained last week in Minnesota. I don’t painfully bang my head in the wall when I realize that I’m going to have to unsuccessfully hunt records down over the next three weeks. Instead, I just open up a “browser.” Any “browser” will do: Safari, Firefox, Chrome, Internet Explorer, or whatever. I go to your health information page, and review all your labs in the format that I’ve customized with all types of “widgets” related to my own specialty and practice. I can see all the notes from multiple physician visits, and amazingly, they are concise and no longer bloated for physician billing, because physicians have finally taken a stand and absolutely refuse to participate in medical documentation gone awry. Oh, and here it is. One alert. You happen to need a lipid panel. Click here to order it. Done.