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More Joys of Electronic Medical Records

Go up to your favorite emergency department staff member and ask them what they think of “twofers.” Depending on that person’s mood, chances are that you’ll get anything from a scowl to a punch in the gut in response. Two patients from the same family both needing emergent medical care at the exact same time? It still happens … car accidents, fires, maybe a stomach bug. But it can be frustrating. There’s a saying in emergency medicine that the likelihood of a true emergency is inversely proportional to the number of patients in the family registering to be seen. That being said, a “fivefer” will raise the hairs on the back of the neck of pretty much any emergency department personnel. When the complaint is that everyone in the family has a cough, three of the five family members smoke, and none of them got their flu shots … well … you get the picture. One of the frustrations with scenarios like this is the charting involved. The nurse and the doctor are literally stuck at the computer for 30 minutes each, both entering useless information about different patients over and over again – instead of taking care of other patients. The medical records won’t let you proceed without entering the information. Is there a fall risk? Is there a risk for tuberculosis? Does the patient smoke? Nurses have to enter this information even on infants to satisfy government regulations. Is there a risk of danger in the home? Is there evidence of abuse? When entering an order for IV fluid, if the patient has a sulfa allergy, doctors have to acknowledge that there is some potential interaction between saline and the patient’s allergy and describe why we would dare to give salt water to a patient with an allergy to sulfa. And on and on and on. So I tried something that sounded easy when I thought of it, but was technically quite difficult when I tried to actually do it. I tried to log the number of times I clicked on different check boxes and the number of different screens I had to navigate in order to document on and discharge/admit a patient. This is easier said than done. I never realized how quickly I am able to navigate a byzantine array of computer screens. After clicking on one button to order a medication, I found myself subconsciously moving the mouse to the area of the screen where the next “OK” button would pop up. I had to literally slow myself down to count the clicks and the screens. I’m sure I missed a few in the process. The number of data points in each aspect of a patient’s history is quite large. There are 144 data potential points to click on just for a patient’s physical exam. The screen to the right is what must be navigated for each and every patient’s history. Each line in the white fields is a data point that must potentially be either right- or left-clicked depending on whether it is positive or negative. I didn’t even bother counting up how many potential data points could be clicked upon, but it numbers in the several hundreds – depending on the presenting complaint. So I set out to log the clicks and screens. The first few times I tried, I wasn’t able to do it. Finally, when it wasn’t so busy, I made a conscious effort to stop on every screen and mark down clicks and screens. I use some basic templates, so the amount of clicking that I do is actually less ...

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CMS Offering Us Some Rope

Our beloved government is now seeking comments on how it can deny payments to hospitals through patient assessment of the emergency department experience. According to this entry in the Federal Register, the “Consumer Assessment of Healthcare Providers and Systems” (“CAHPS” for short) doesn’t address patients’ experiences with emergency department services. So the Centers for Medicare and Medicaid Services (“CMS”) is seeking “a rigorous, well-designed emergency department survey will allow us to understand patients’ perspectives on their experiences in emergency departments and how such experiences change over time” … and that will allow them to deny or reduce payments to emergency departments that don’t comply with its arbitrary and irrational standards. In other words, CMS is saying “Here’s a bunch of rope. See if you can form a knot that will form a big loop at one end and that will support the weight of an average human.” And I’m going to snap if I hear one more person say that “we need a seat at the table or the decisions will be made for us.” Newsflash: We’re not invited to be “at” the table, we’re what’s on the menu. They aren’t doing this to make medical care “better.” They’re doing this to find a way to justify cutting payments further. You want to see your emergency medical care funding dry up because you had to wait too long or because you didn’t get your Dilaudid shot soon enough, that’s your business. As more and more hospitals close because the government pays them less due to your bad scores, you are essentially rationing your own care. I’ve had people argue that emergency departments need to be evaluated and regulated. Stop for a minute and think about why you go to the emergency department. Do you go there just to be seen quickly? Do you go there just to get pain medication? Do you go there just so that people will respect your privacy? Do you go there so that people will listen to your complaints? If that’s all you’re rating, the medical system will adapt to meet solely those expectations. Look at how businesses are adapting to cope with the Affordable Care Act’s new requirements. If ratings are based solely on non-quality measures, you’ll get someone that sees you right away, gives you a pain shot quickly, makes sure that your gown covers you, holds your hand for a minute, maybe gives you a prescription for an antibiotic or two, and discharges you to some other doctor to find out what’s causing your problem. And you’ll pay more money for it because the hospital will need to make up its losses on those who pay for their care. Therein lies the problem. If surveys de-emphasize quality care, then hospitals will de-emphasize quality care. Think I’m wrong? Watch what happens when government pays hospitals based on capitation.  Remember the old HMO days? They’ll return with a vengeance. With decreasing reimbursements, there won’t be any way not to decrease the quality of care. Remember the engineer’s triangle? When the government comes up with a “Consumer Assessment of Government Providers and Systems” that allows us to pay taxes based upon how satisfied we are with our government providers, I’ll listen. Can anyone come up with any reasons why such a rating system will never happen? Now apply those same reasons to the hospital and emergency department rating system proposed by CMS. More patients, fewer hospitals, government mandated “insurance” that pays less than the cost of care, and more ways to cut payments to providers. What could go wrong? Boy am I glad I’m a doctor.

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Choosing Wisely – Good Medical Practice or Prelude to Rationing?

EP Monthly has an important Pro-Con debate between ACEP President David Seaberg and EP Monthly founder Mark Plaster about the “Choosing Wisely” program. Choosing Wisely is being pushed by the ABIM Foundation as a way to get specialty societies to label certain tests as “unnecessary” or of questionable benefit. I side with Dr. Seaberg in this argument. I disagree with the concept some people advance that we need to essentially “do it to ourselves before someone else does it to us” (see the comment to Dr. Seaberg’s position). Reasoning like this is how physicians and patients have lost much of the control of the house of medicine. Read through the news and look at the emphasis on reducing the amount of “unnecessary” care. Just last week, the Washington Times published an article about how the Institute of Medicine stated that we waste $750 billion each year in health care. How could anyone disagree with reducing that which is “unnecessary”? It’s a great sound bite. But as Dr. Plaster notes in his article, the devil is in the details. How do we define “unnecessary”? A pregnancy test in a male patient is “unnecessary.” No way to justify its use. But other tests which seem to have little clinical utility may be deemed “necessary” for non-clinical reasons. A CT scan may only infrequently show the etiology of a patient’s syncope, but some doctors may believe the CT scans are “necessary” to avoid accusations of improperly evaluating a patient or to prevent being sued for missing a rare neurologic cause of a patient’s syncope. If we want to decrease the amount of “unnecessary” testing, we need to address all of the reasons that such testing is performed. Why doesn’t Choosing Wisely change the preamble of its campaign to include: “The following tests are medically unnecessary and no type of professional or legal liability should ever be imposed upon physicians for failing to order or perform them …”? I question whether the ties that several ABIM foundation trustees have to the Obama administration (hat tip to A Line of Sight) will affect the mission of this project. Finally, many of the groups listing “unnecessary” testing in the Choosing Wisely campaign are making their directives at other specialties. Radiologists are telling emergency physicians not to order so many CT scans. Neurologists are telling emergency physicians not to order CT scans for migraine headaches. Unless those specialists are going to come to the emergency department, evaluate the patients, and follow their own recommendations, they have no business telling other specialties what to do. Easy to point fingers when you have no skin in the game. We need to reduce the amount of testing performed in this country, but I still think that the best way to do so is through deregulation and free market principles. If patients want to pay for a test with little clinical validity, they should be able to do so. They should be able to have the test done ten times if they want to pay for it. Patients should be able to make an educated decision as to whether they want a have a test performed. And physicians should function as advisers to the patients in this regard, not gatekeepers who deny testing. In this respect, I predict that Choosing Wisely just won’t work for its intended purpose and it will likely be used as a first step toward rationing care – especially care that ends up with “normal” results.

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Certificates of Medical Necessity

  Not too long ago I got a letter labeled “URGENT” in my mailbox at work. The letter was from Walgreens regarding a patient I had seen several weeks earlier. I cut and pasted parts of the letter to make it fit on one page above. As the prescribing physician, in order for our government to pay for the prescription I wrote for the patient … several weeks ago … I had to sign a statement stating the following: “I, the undersigned, certify that the above prescribed supplies/equipment are medically necessary for this patient’s well being. In my opinion, the supplies are both reasonable and necessary to the accepted standards of medical practice in the treatment of this patient’s condition and are not prescribed as convenience supplies. By signing this form, I am confirming that the above information is accurate.” Seriously? To get reimbursement for a medication on the $4 list, the government is forcing health care providers to take the following steps: A pharmacist has to receive the denial from Medicare, look at the medication, enter all the information into the CMN and generate a letter to me. The pharmacy must then spend 44 cents to mail the letter to me Once I receive the letter, I don’t remember the patient, so I am then forced to waste time looking up the patient’s chart, reading through it so I could find the diagnosis and make sure that the flipping $4 albuterol prescription wasn’t for the patient’s “convenience.” The pharmacy then spends another 44 cents for the self addressed postage paid envelope. Once the pharmacist receives the certificate saying that the patient really does need his albuterol solution, he then has to spend more time going back on the computer, matching the signed statement with the visit and then forwarding the claim onto the government for medication that has already been dispensed. Then the pharmacy waits months and hopes that it gets back $3 in reimbursement for a $4 medication. In essence, health care providers waste 50 times as much value in time getting paid for something after the fact than the item is worth. And the government knows it. It is just hoping that one of the providers won’t do all the paperwork so that someone else gets stuck paying for the medication – other than the government. No paperwork, no payment. Is this what medicine has come to? Harassing providers so much with pre-authorizations and post-authorizations because they don’t have enough to do? What other ways can we concoct to steal services and supplies from medical providers? Then I thought that since the government uses these authorizations so much, that they must be a good idea. Before I send in my next tax payment, I’m thinking about sending in a similar authorization to the IRS. “I, the undersigned, certify that the above tax payments are necessary for this country’s well being. In my opinion, the government purchases made with this money are reasonable and necessary to the accepted standards of accounting practices and are not spent on wasteful or potentially wasteful projects or items. By signing this form, I am confirming that the above information is accurate.” Any accountants out there? Would this work?

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We're From The Government, We're Here To Help …

The clock is ticking for Parkland Memorial Hospital in Dallas. Last week, Parkland was cited by the Centers for Medicare & Medicaid Services for several “serious threats” to patient safety. As a result, the hospital is now in jeopardy of losing its ability to participate in the Medicare program unless it submits “correction plans” to CMS by August 20, 2011. According to a CMS spokesperson, two violations relating to infection control and emergency care issues were “so serious that they triggered ‘immediate jeopardy'” for the hospital. In fact, the reasons for the citation were so heinous that CMS won’t even disclose them to the public until Parkland submits plans on how to fix those super secret problems. That’s the subject of another WTF discussion, but we’ll save that one for later. The event triggering the CMS investigation involved a schizophrenic psychiatric patient with a heart condition who died while in the emergency department. The report states that the technicians who subdued the man did not have “effective training” and that the patient was not closely monitored before his death. According to the article and an interview Parkland’s Chief Medical Officer, Parkland was cited for several reasons. Based on what I can gather from the article, two of the hospital’s citations were for: – Moving patients with less serious symptoms to a separate urgent care center for medical screening – Staff touching a patient and then touching other surfaces that people would come into contact with Think about how grave these dangers are. When a patient is more than 20 weeks pregnant and has abdominal contractions, what happens when she comes to the emergency department? She gets put in a wheelchair and brought directly to the obstetrical department for further evaluation. So by virtue of their presenting complaint, some pregnant women are immediately sent to a different department for medical screening. This process is apparently acceptable for CMS because it happens everywhere in the country. Suppose the same 20 week pregnant patient has a hangnail instead of being in possible labor. Now, instead of moving the patient to obstetrics for pregnancy evaluation, Parkland was moving the patient to its urgent care department for further medical evaluation. Both “moves” are made based upon a patient’s presenting symptoms. However, when a patient with one presenting complaint is sent to one area of the hospital for further evaluation, it is entirely acceptable while sending the same patient to a different part of the hospital for a different presenting complaint constitutes a “serious violation” and a “threat to patient safety” that must be stopped immediately. Makes perfect sense to me. Then there’s the “let’s have a sterile universe” violation of epic proportions. Touching a patient and then touching surfaces that other people may contact is a “serious and immediate” health threat? Let’s see this logic. I’m assuming that the government means that it is a serious health threat to potentially transfer germs from one person to another. What should healthcare providers do in order not to create a “serious and immediate health risk”? All bathrooms must be completely sterilized between each use. After all, one patient could come into contact with a surface that another patient touched. Doorknobs to all hospital doors must be sterilized after every person touches them. After all, one patient (or worse … a visitor [gasp]) could come into contact with a surface that another patient touched. Beds. Walls. Chairs. Everything must be sterile, dammit. Otherwise, we’ll all crumple up and die like those things on War of the Worlds. Do I think that medical providers need to wash their hands ...

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Medicare Cuts Delayed Again — PHEW

I had planned to log on and write a quick post reminding docs that they have less than a week to decide whether or not to remain a participating provider in Medicare in the face of 21% payment cuts — and to encourage docs to drop Medicare. While perusing the morning news, I discovered that once again the Senate has made a last-minute decision to delay the Medicare pay cuts — this time until October 1, 2010. I’ll be linking back to my Brinksmanship article somewhere around September 15, 2010, I’m sure. According to one Senate Republican, this means that the federal deficit will increase by $100 billion. Wait. Seven months of foregoing 21.2% cuts to physicians costs the government an extra $100 billion. That means that 12 months of foregoing cuts would cost $171.4 billion (divide $100 billion by 7, multiply by 12) Dividing $171 billion by 21.2%, we get a total Medicare payout to physicians every year of $808.6 billion dollars. Mrs. WhiteCoat gets paid about $70 for an average office visit for a Medicare patient – usually after having to pay her office manager for a couple of hours of time to figure out why Medicare refused to pay the first three times the claim was submitted. Let’s round up. Say Medicare pays $100 for an average doctor visit. Dividing $808.6 billion dollars total physician payments by $100 per doctor visit means that the total number of doctor visits – just for Medicare patients – is a little more than 8 billion per year. Lets say that there are 50 million Medicare enrollees (these Kaiser numbers are from 2008, so I increased the estimate from 44.8 million to 50 million). Eight billion visits divided by 50 million patients means that every single Medicare patient is seeing a doctor an average of 161 times per year – more than three times per week every week for the entire year. Look at it another way. Dividing $808.6 billion by 50 million Medicare patients means that physicians are being paid an average of $16,172 each year for every Medicare patient in the country. So what are all of us rich doctors complaining about? How about politicians who are full of hot air. Where’s the money really going?

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