The "Ohno" Moment

 About a thousand years ago as an IT manager, somewhat, I had to conduct training for my users on that new tool called "The Internet."

Incorrectly, as most pedants, including myself, will point out.  Granted, I did come about this knowledge back in the day when "The World Wide Web" was in it's infancy, so I suppose, the description of me still fits.  But I - as ever - digress.

During that training, I informed my folks that the company would be providing them access to the internet, but we would also be monitoring their use of it.  Filters and other tools weren't invented quite yet, and the browsers that did exist were all in single-digit versions, and when improvements were released, they were noteworthy, not ... Oh, hey, there's a thing popping up on my screen telling me I need to upgrade the third time this week...

But getting back to the point.  I would tell folks that it is entirely possible as this tool evolved that they may find themselves on a web site with content they hadn't intended to find.  Things that might be considered minimally as unprofessional, or a whole heck of a lot worse.  So, I told them, I was going to define something called an "Ohno" moment.  That term, I always said, was instead of using the expression that typically came out of most people's mouths when they discovered they weren't where they thought they should be, and knew there might be trouble.  So rather than send people off to report me to my supervisors for labeling such an event with a profanity, I chose to call it the "Ohno" moment.  That instant where you realize the content appearing on your screen may be a problem.

And for those who think I was just being scary, I had a tool which I ran every morning.  A tool I'd built.  It copied a list of all of the URLs which had been recorded by the server to another file.  I then used a batch file to filter out various sites which were legitimate.  Then I had to review a few hundred lines a day.  Inevitably, as things do tend to evolve, I was adding more sites to be filtered out of the list to review, and then reporting myself to my own supervisor when I encountered the very rare sites that I had to check.  

Going along with that was the other part of the training, where I'd have to tell my users that, as their employer was providing them with these computers and services, their employer would be monitoring their use, as their use of these resources might create legal liabilities not only for themselves, but for the corporate entity that paid them, so they, in turn, had no expectation AT ALL (I spoke in capital letters, I joked) that they had ANY privacy when using them.  And please be considerate, so that we do not have to restrict, regulate, or otherwise reduce their ability to use the resources.

This moment grew, in part, out of an experience which I had as a younger computer user.  I had sent a message to a friend of mine agreeing with his assessment of a coworker who was difficult, often prone to mistakes and required a lot of re-working their mistake.  As one might expect when you put something in writing, it very rarely stays in the narrow band of exposure which is intended.  My message somehow, and the how is not important - was not then, and is not now - found it's way to the individual who had been the subject of the discussion.  

I learned a number of things, not the least of which was to stop and think before I type.  To this day, as I type emails, chat messages, or memos to others for any reason at all, I re-read and review the message before sending it on, looking at it from the perspective of someone - anyone - who might wish to take portions of it out of context.

So this past week, when I found myself dealing with an emotionally difficult, highly tense situation that I normally would not have been responsible for, but as a more experienced person who knew many of the individual particulars, I had been asked to step in and assist for the person who was taking a vacation.  None of the difficulties arose from that individual's handling of the situation, or anyone else whom I normally work with.  The situation began because someone unaware of proper procedures or even blessed with an understanding of our process chose to insert themselves into a delicate situation and proceed to alienate many people on whom we depend and need to maintain a good relationship with in order to provide the services we provide.  

In doing this job, I have been trained - intentionally and otherwise - by coworkers and the simple act of doing the job - to think like, and view every situation from the viewpoint of a person who must rely only upon the information I provide.  Working in healthcare, we are restricted by a number of laws and requirements, so that when I have to ask an insurance company for something, I know that the information I provide is very likely going to go through a number of hands.  Some of those people are going to be like me - relatively low level reviewers who do not know the meaning of some of these terms and situations - they are simply looking at the request I am making for the specific medications the patient is to receive, and checking those items against a list of things which their company is happy to tell us they do not need review.  There are a large number of extremely expensive, effective, and even miraculous medications, but there are a much larger number of medications which most insurance companies determine are perfectly understandable.  

I have a number of tools on my work computer to allow me to determine, based on the insurer, if a medication or service will need to be reviewed.  I also have five years of job knowledge, which permits me to look at certain situations and know they will be challenging, require a substantial amount of time and monitoring, and need to be handled carefully.  I'm always careful with patient data, but some situations are quite a bit like trying to get through a mine field.  I have patients who have chronic conditions who require therapy daily over many years.  Some for a lifetime.  Some of these patients require that I inform their insurance company on a regular basis that the patient is continuing service.  Some of these patients have good, responsible, reliable payers.  Some of them have the coverage they have been able to get, and the payers are often shall we say difficult.

Look, I'm lucky.  I live in a state which does not permit a hospital to be a for-profit enterprise.  This puts me in a position where, when I deal with a vast majority of most of my patients who don't live where I do, I find myself often a bit disgusted by what I see.  I do understand that organizations - all organizations, mine, and every other organization that employs people - must operate in a fashion that causes them to bring in money that at the very least meets the outgoing demand for money - that means the organization can continue tomorrow to do what it is they do.

But when I encounter organizations which often make decisions that do not seem consistent with previous behavior, I can't just shrug. I've been the patient, the person stuck in the hospital for whatever reason, though in my own case, it is usually because I've attempted to reason and treat myself to the best of my knowledge.  And history has shown that, had I gone to medical school, I would be a terrible doctor, because I sure as hell don't know what I am doing on many occasions.  

But back to the point.  I had a situation where a patient needed care.  I had an insurance company to whom I had to introduce myself, as it was an organization I do not often deal with.  The organization is somewhat widely known among my fellow coworkers to be one of the more challenging, as they will often require additional documentation for specific services.  A normal situation for me might find me submitting anywhere from four to fifteen pages of information when I request an authorization, which is what the insurance companies call what it is they provide us - approval for a patient's therapy, often during a specific range of dates.  At the end of those days, we may need to go back to the insurance company and provide reasons that the doctor has determined are sufficient for them to order the therapy continue, until the condition is resolved.  We don't say "cured" because, as with most life, there aren't cures.  There are therapies which can reduce a situation from life threatening or simply challenging to undetectable.  If we say "cured" however, and then the condition returns, there are a number of persons from the legal profession who might wish to point out that, as the condition was noted to be resolved, and it returned, it might be our faults for that.

Or, to put a much finer, less professional point on it, there are some ambulance-chasing lawyers out there who would like to make their name and a few bucks at our expense and on the back of the poor person who's condition reoccurred.  But this is life, and as the very, very old joke goes, it's almost always fatal.  My own personal beliefs do require a caveat stating that, so far, we've had two folks who, based on the very old, available documentation, may have gotten out alive.  

But again, I digress, back to my point,.  I had a patient who needed therapy.  I was asked to involve myself into an already-difficult situation because it was not going well.  I discovered a number of issues with how the situation had been addressed to that point, and immediately took steps to insert myself into the situation, make the appropriate contacts, and clearly reduce the tensions and confrontations to a point where we might be able to focus on the required therapy for our patient, and not the various points of conflict that had already become the focus.

After professionally introducing myself, making contact, and accomplishing the primary point of my job - obtaining approval for my employer to provide services to the patient with the assurance that we may have a reasonable expectation to be compensated for our services, I considered the event properly and successfully concluded.  I was congratulated by several of my supervisors for this.  Then an issue arose due to someone not understanding the five years of experience I have, which leads me to evaluate each and every situation based solely upon the states and situations I can support with documentation.

In this particular case, there was some information which I usually find myself noting as "open to interpretation".  In these events, I have to look at what it is I can support and accomplish based on the strict interpretation of the documents.  And in this case, it came down to what's on the page.

Often, when you go to the doctor for a specific condition, you're given a prescription.  In our world, that's called "Orders."  As a young child, and even into adulthood, those prescriptions took the form of a piece of paper.  You hand carried it from your doctor's office over to the drug store, where another medical professional looked at that paper, interpreted what was on the paper, and filled a bottle.  In these internet days, those paper documents are rarely on actual paper any longer.  They're in the form of an electronic message often printed to a PDF file that details the name of the medication, and seven other elements.  They include how much of the medication the patient will get, and how often they will get it.  There is also, in my corner of health care, a method of delivery, a duration, and most importantly, some form of identification to permit us to know who it is has made this determination the medication is appropriate for the condition.  We need a diagnosis which is sometimes included on those orders, and sometimes it comes from pages - sometimes a few, sometimes thousands of pages collected from a lifetime of medical care - from the patient's history.

But very often, we will get orders which tell us when the service starts, and when it ends, on a specific date.  We also get things like "for six weeks" or something similar.  Most people do not know that a doctor's order, in our world, is good for one year.  We expect most people to get the treatment immediately, but some treatments can wait.  Sometimes we get therapies that are "as needed" or "PRN" as we know it.  I don't know what PRN stands for, but I note these just to show what sort of ranges we're dealing with.

I often see therapies with start dates before I get the documentation.  That's because the doctor says "six weeks of [medication]" and it starts when the patient is hospitalized.  Some patients may be released the next day, some are more often released after confirmation the therapy is working, and some may be due to other conditions which required treatment.  But on any given day I will see orders that state anything from "four doses" to "one year".  We have been trained to start our requests on the earliest date to cover that first dose.  Which means, when we get an order dated Tuesday that we'll ask the insurer to start our approval on the same day, unless the order is dated for Tuesday and says therapy starts on Thursday or after some key defined event.  In those cases, we then need documentation showing that event has happened - whether it's a particular test showed some level is at the appropriate point or the patient has, in the simplest form, just gone home.  Whatever it is, that defines the start.

Absent any other date or defined event, we start on the day of the order, which has to be dated, one of those required elements.  In my situation, the original request, which I did not submit, but supported, had a start date before another required event was completed.  The reason I did not change the date was first off because I was not aware the event was required, as it was not noted in the patient's documentation, and secondly because, due to the urgency of the situation, it had been communicated to me that we needed things to happen "right now".  

All of this put me in a position that showed up this past week.  I had asked for and received approval for a specific date range, which was two days short, due to the other event.  I informed the folks I was working with that, due to the history we have with the particular insurer, we would need some specific documentation to indicate that therapy should continue.  In that discussion, someone whom I've never met, never knowingly dealt with, and someone who had not been fully aware of the history of the situation unloaded her frustrations on me in what I have been told was an unprofessional manner.  I am not fully equipped to make a reasonable, dispassionate evaluation of the situation due to my proximity, but I recognized the frustration and the anger as pushing the individual to making statements that, had it been me, and had I been perhaps another 35 years younger, I might well have mashed the enter button on the keyboard with genuine fury.  

Given the prevalence and ease of use of today's now nearly instant messaging using the internet, it's not too surprising that some folks have forgotten the "Ohno second" rule #2 - that is, when in the heat of the moment, stop, step back, and think about it - is this message something you'd be happy to show your grandparents?  Your supervisor's supervisor's supervisor?  Or the person to whom you're sending it's supervisor?  Yup.  

So, in what the kidz these days are probably calling it, I got blasted in a message someone wanted to use to get out their frustration, anger, and irritation that covered the fact that the situation was, at least in part, due to haste, incomplete information, and poor people skills.   Yep.

And I, being the poster child for the Fuckwit moment, that is, when one replies to such a message without thinking it through, started typing.  I typed up a very scathing response.  And immediately, CAREFULLY, deleted it - before pasting it into the tool and hitting send.  Yeah, that's right, kids, I have learned to keep a spare Notepad window open because some keys are awful close to the Enter key, which is the key most of these instant-message tools use to do what we used to call "commit" - that is, send the message.  Take it from my screen to the one, ten, or ten million other screens which will see it.  So rather than inadvertently sending a message with a typo - or a misuse of language - like "there's no their they're there" - I will typically type any response of more than ten letters or so into a notepad, review, then copy and paste.  

And that message was not pasted - nor did I leave it in the notepad.  I deleted it.  Then I got a message from one of my supervisors, who wanted to speak with me.  And the first thing she said, anticipating my apology for letting the situation go so far off-topic, was that I had remained professional, I was not in trouble, she was talking directly to the supervisor of the person who had sent the message, and that individual would not be part of the situation or conversation.  And that the person's supervisor was going to be reaching out to me to apologize.  I informed my boss that the apology was not necessary, I was familiar with frustrating situations and well aware that anger and frustration often say things we'd never say to someone else.  I expressed the same thoughts to the supervisor in our conversation.  

There's no point in bearing grudges, they do not provide patient care.  Nor do they improve the workday.  Or work environment.  And this particular situation was extremely out of character for the folks I deal with daily, and was likely due to the tense environment that always surrounds any request for this particular insurer, not just those that started like this one did, which was terribly.

So I scored points, being an adult, not behaving like a wounded child.  So I guess I can be taught.  We'll see how long that lasts.  

But in the end, the bottom line is that the patient is getting the therapy they need, hopefully it will resolve the situation successfully, and we won't have any further issues in the next week or so, because you never know when any patient might return, because, well, they had been feeling better, the test results had looked great, but then something else happened.  Yup.  It's called life.  You won't get out alive, neither will I.  The best we can do is hope to be reasonably healthy, in full command of our abilities, and able to provide self-care up to very nearly the end of this whole thing,.  At least, that's my goal.  I should probably get on with it, then.