Let the Patient Write The Referral Letter

On the portal this morning I received a great note from a patient. He’d seen two specialists and was checking in to tell me what had happened in those visits. His summaries were succinct, tell me exactly what I needed to know about what transpired. It took me about a minute to read them. Since the advent of EHR-generated referral letters I’m unsure that I’ve read a better referral note.

After reading it, I knew the assessment of the problem, the treatment plan and when he would be seeing them back. I did NOT receive one to tenMedical_Software_Logo,_by_Harry_Gouvas pages of past medical and family history that I already knew. I did NOT receive a list of the medications he walked in the door on, which I already know. I did NOT receive his insurance information, which I already have. Etcetera.

When will EHR vendors be able to extract information and template a referral note that only contains what I need and not streams of unnecessary information that gets in the way of my being able to read what I do need to know? When will physicians help the IT department cut out all the useless crap in those letters? If they’d like the name of my patient to help them, please contact me. I’m sure we can work something out.

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Question: When is a Screening Colonoscopy not a Screening Colonoscopy?

Answer: When the insurance company decides it is not.


A Healthcare Puzzle

The definition of screening, from a health prevention viewpoint, seems pretty straight forward: “a strategy used in a population to identify an unrecognized disease in individuals without signs or symptoms.”[1] Typically these services are covered at 100%. However,  insurance companies avoid appropriate payments for their members by changing the coding of a preventive service (which is covered 100%) into a diagnostic procedure, which is paid based on whatever the patient’s coverage allows. This change in coverage occurs because a polyp is found during the exam, which is of course, the whole point of doing the procedure: Screening and removing a polyp so that it never becomes cancer.   Patients with high deductibles suddenly owe several hundred dollars in unexpected healthcare bills for a procedure they were told was covered. This is ethical and appropriate corporate policy?

And I can’t help but mention that the insurance company fancying itself a “Healthcare” company, promoting health and well-being, is the worst offender.

Subsequent colonoscopies that must be done five years later for individuals with polyps, instead of ten years,  can arguably be called diagnostic. But changing the definition of a procedure solely to avoid paying for an appropriate screening exam, is another example of non-transparency, regardless of how well you explain it in the patient’s policy description.



1. http://en.wikipedia.org/wiki/Screening_%28medicine%29

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A Better Idea for the Post-Visit Phone Call

256px-Google_voice.svgThis morning an article caught my eye and then my imagination: The Dreaded Post-Visit Call. It describes a patient who becomes worried after getting a post-doctor-visit phone call. She doesn’t understand its purpose and calls her physician thinking something is terribly wrong. Apparently his healthcare system employs individuals to make these calls after every doctor visit to ensure “patient satisfaction” (THAT PHRASE!). At any rate, it got me thinking about the future of calls like this.

It is not outside of reality to envision other entities making post-visit calls.  The doctor’s employer can use the data to determine bonuses. This call could be followed by a post-visit call from the patient’s insurer. These calls could collect data to be used to determine if an insurance company will continue to keep a particular physician in their network based on some sort of satisfaction algorithm. It’s not hard to imagine CMS (Center for Medicare Services) getting on board with this as well as private insurers. Maybe the federal government could get further involved to create a Patient Satisfaction Data Bank. That could be the patient’s third call. And since nothing seems to be private anymore, Healthgrades could make a post-visit call when a patient tweets or posts to Facebook that they were in Dr. Jone’s office. This would increase the number of individuals rating doctors and isn’t that a good thing? Or is it…Why Rating Your Doctor is Bad for Your Health?

Let’s get more anonymous individuals involved in patient’s care, ticking off boxes for corporate data gathering. Or maybe, healthcare systems could train and employ health coaches who do know the patient. Getting a phone call from someone who really cares if you understood what was said during the visit and that you know how to make changes to improve your health? The same person who scribed your visit maybe? This would also free up physicians from being distracted by a computer screen and help them make a better connection with their patients.

Wow–a real win-win for patient care and engagement!



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Designing for Health and Happiness

Yesterday my feed sent me an interesting article on the iMed Apps website. The Slideshare below by David Sobel, Director of Patient Education and Health Promotion for The Permanente Medical Group and Kaiser Permanente Northern California, is intriguing. Looking through the slides, they resonated in me. Burnout has crept back into my daily existence and some days it’s as if I’m fighting it  tooth and nail, yet not making much headway. The slides are worthwhile to see for patients and doctors alike, both searching for the motivation to make lives better–our own and the patients that we care for.


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Patients–do you consider yourself a leak problem?

Healthcare Leakage

Healthcare Leakage

My LinkedIn update this week referenced a term I recently became acquainted with when it was used by an administrator in my system. It seemed vaguely offensive at the time but I couldn’t quite get my head around it to understand why. It’s called leakage. When this article, “How to reduce patient referral leakage” popped into my inbox, it hit me–is this going to be one more set of numbers administrators can threaten me with? I understand this is a term used in other industries to refer to the consumers they are losing to competitors and I’m fine with that. However, what does leakage mean to a doctor? It’s what aging bladders do. It’s what comes out of an infected wound sometimes, or an imperforate anus. When doctors use the term leakage it is not a pleasant visual. Maybe a tube is Screenshot 2014-09-14 18.52.51blocked. An organ is swollen. The idea that my patients are being referred to in this way is offensive.  I’d like to do a study with my patients. “Tell me, how do you like being referred to as leakage if you go to another healthcare system or an independent imaging facility for your healthcare needs?” Somehow, I suspect I already know the answer to that question.

The way we use words is important. Leakage is simply not an appropriate term to use in healthcare. If I didn’t have faith that my system employs some of the best doctors around and takes extraordinary care of patients both inpatient and outpatient, I wouldn’t be working for it. Unless my patients request otherwise, and they seldom do because they trust me and they trust my system, they are referred within. But how much trust would they continue to have in me if they knew I was being pressured to refer in-system? Let’s stop talking about leakage and instead attract the best doctors to take care of our patients because they deserve it. Let’s make our system one where the best doctors want to come and know their patients will be well cared for. Let’s put our patients first and they will continue to come back to us. Let’s be careful with our terminology. Just because other industries use a term that does not mean it is appropriate to use it in healthcare.

When the chair of the board brings his daughter to me and she needs to see a cardiologist do you think he’s going to want me to choose the physician she sees based on who employs her? I suspect not.  And next time he or anyone else uses that term around me, be prepared for an earful. My patients are not leakage. You will not refer to them as such in my presence.

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Vaginal Estrogen–a High Risk Medication in the Elderly?

There is a wonderful expression used by the French when referencing an older woman. She is “a woman of a certain age” (une femme d’un certain age) Recently. a patient who fits in that category, began suffering from vaginal dryness causing burning and pain. This is impacting her sexual function as well as being just plain uncomfortable. So I prescribed a vaginal estrogen which serves to increase the vascularity in the area and “plump” up the cells. This improves things in general and reduces the discomfort of sexual activity. Her insurance company, a prominent one in our city, requested that I obtain a Prior Authorization but still denied payment for the prescription because it is a “high risk medication in the elderly.”

Oral estrogens are high risk in the elderly, defined as over 65, increasing the risk of stroke, breast cancer and memory problems. This woman is not at all elderly in the sense of being infirm. She walks daily, volunteers weekly, travels widely, has an active sexual life with her husband and could no doubt run circles around half the people involved in the denial of her medication. The lowest cost vaginal estrogen preparation costs about $168 a tube and there isn’t a generic alternative.  In an article published in the American Journal of Obstetrics and Gynecology in 1981, there was NO systemic absorption with low dose vaginal estrogen.(1) A study in 1983 published in the Journal of Clinical Endocrinology and Metabolism showed essentially no changes in the systemic markers of estrogen.(2) While I suspect that no one at the insurance company is maliciously denying claims,  did their pharmacy committee bother to do its homework regarding the difference between vaginal estrogen and oral meds?

Low-dose topical estrogen is significantly safer in women over the age of 65 than oral preparations. This should be a choice between a patient and her doctor NOT a “member” and her insurance company.

1. American Journal of Obstetrics and Gynecology. 1981 Apr 15; 138(9):967-8. – See more at: http://www.popline.org/node/385377#sthash.kkgLZIvI.dpuf
2.Biological Effects of Various Doses of Vaginally Administered Conjugated Equine Estrogens in Postmenopausal Women http://press.endocrine.org/doi/abs/10.1210/jcem-57-1-133

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Yes Cassie, there is a future in Primary Care

My daughter recently introduced me to a friend of hers via email. She is a newly minted fourth-year medical student who asked me the following question:

“I would love to hear your thoughts about the future of primary care and what it is like to work as a family medicine doctor in Louisville.”

To start, I’d encourage you to read this recently published New York Times review of the state of primary care.  If you began in practice today you would quickly find yourself with more patients than you can adequately care for having just left residency and not expecting to see 25-30 patients daily. In Louisville, you will probably be employed by one of three healthcare systems. All of them have compensation based on patient volume and RVUs–I hope someone has showed you what RVUs are but I bet they haven’t. Relative Value Units are supposed to measure the “time, skill, training and intensity”[1] of patient care and compensate accordingly. Unfortunately they are heavily skewed toward proceduralists. As Dr. John Mandrola, john-mandrolaa Louisville interventional cardiologist, observes in his excellent post Thirty Dollars…Really?, a doctor is paid a lot more to do a coronary catheterization than to talk about the causes behind coronary artery disease. To understand a little more why the RVU is skewed that way, here is an excellent post on the Kevin MD blog that summarizes it nicely: The Relative Value of How Physicians are Paid Needs to Change. So in today’s environment you need to see more patients than you are comfortable with, spend less time than you deem adequate with them which will promote pill-pushing over explanations. This will mean your risk of burnout will be significant. It is estimated that 43% of Family Practice physicians are burnt out according to a Medscape survey done in 2013.[2]

There is some good news. Value-based care, which bases compensation on how well you take care of patients rather than the number of patients that you see, is coming. In our corporation, systems are being put in place that will help primary care doctors take quality care of their patients and compensate those that do it well better than the ones that don’t. Of course how one is measured is controversial as evidenced by this NEJM article from November: Grading a Physician’s Value. And data can’t be gathered without an integrated EHR (Electronic Health Record) and those are far from prime time. Being a digital native,  you’ve likely already noticed that EHR software on your rotations is not up to the gaming software standards you are used to.

Social Media, regardless of what city you ultimately practice in, will be the best means of keeping up with the ever-changing landscape of medical advances, political hot potatoes and healthcare tech so if are not following healthcare thought leaders already on Twitter I’d advise you to start that today. Begin with Primary Care Progress (@PCProgress), Berci Mesko (@Berci), Screenshot 2014-07-23 14.57.20Mike Sevilla (@DrMikeSevilla), John Mandrola (@drjohnmd), Kevin Pho (kevinmd), the Society for Participatory Medicine (@s4pm) and me (@docnieder), of course. If you haven’t found ZDoggMD, that’s another must.

Primary Care is alive and, if not well, at least no sicker than the rest of healthcare in the world but I see better things on the horizon. If I were fresh out of residency today I would get my feet wet as an employed physician for a couple of years, making sure your non-compete clause does not include going into private practice but only prevents you from moving to a different healthcare system across the street. Then I’d look long and hard at the DPC movement (Direct Patient Care) and make that my goal. Taking care of patients in an atmosphere that values the doctor-patient relationship above all other business needs is what we go into medicine to do. Physicians in DPC are happier and so are their patients. While it remains a patient care area where it is difficult for lower income patients to access, this may change as this successful way of caring for patients brings down costs and increases quality. I believe that government entities will find ways of incorporating this model into their systems. The  DPC model can be affordable for people who can’t afford health insurance but still make a modest living, giving them an option for excellent healthcare at low costs. For now, a physician can use the time generated by working in an upbeat and efficient model to volunteer at community health clinics like theScreenshot Family Community Clinic offered by St. Joe’s on East Washington St. in Louisville.

  1. RVU BASED PHYSICIAN COMPENSATION AND PRODUCTIVITY. Merritt Hawkins.  http://www.merritthawkins.com/pdf/mharvuword.pdf
  2. Lifestyle and Burnout: A Bad Marriage. Peckham, Carol. Medscape.com. 3/27/2013. http://www.medscape.com/viewarticle/781161
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Unintended Consequences: How HIEs force patients to quit their PCPs.

Last week, a patient who has seen me for more than 20 years called my office for an appointment. She signed up for one of the new HIE insurance plans but we are not a provider on that plan. She is a healthy woman, rarely needing my services and expected her new insurance to be her backup in case she became seriously ill. She was willing to pay cash to see me but this is unacceptable under Kentucky rules and considered “insurance fraud”. The reason given to her and our legal representative, by the Kentucky Healthcare Exchange (KYNECT), is that if a patient can afford to pay for a routine doctor visit then they shouldn’t need insurance. What? How does that follow? Since when does the ability to pay cash for a single visit mean that a devastating diagnosis and subsequent treatment would not wipe a patient out financially? One would assume lessoning that risk would be one purpose of the new insurance exchanges given that medical bills are the #1 cause of bankruptcies[1]! Insurance doesn’t need to be for routine visits. In fact, the entire basis of the DPC movement (Direct Patient Care) is to cut out the middleman of insurance from routine primary care visits.

Because I work for a healthcare system, my staff could not tell the patient what physicians and healthcare advocates “in the trenches” recommend, which is to hide your insurance status from your doctor’s office. There’s a great article entitled “Insured Patients Can Save Money by Pretending to be Uninsured” from the The Self Pay Patient website that explains how this works to many patients’ advantage.

I wonder, is this solely a Kentucky problem or is this an issue seen across the US? If anyone knows please leave a comment in the section below. In the meantime, if you are my patient and I don’t accept your new KYNECT insurance, well, I’m just sayin’…

1. LaMontagne, Christine. NerdWallet Health. http://www.nerdwallet.com/blog/health/2014/03/26/medical-bankruptcy/

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A Short EHR Rant

No argument that EHRs began as billing platforms, though I will argue that they work just as poorly with charging as they do for communicating patients’ stories or making better decisions in patient care. After two years our EHR still isn’t used for billing and even if it were, since it has no Natural Language Processing capabilities, the doctor would have to manually enter the correct CPT code.Medical_Software_Logo,_by_Harry_Gouvas

My rant today is a brief one about how physicians document in an ambulatory EHR. On paper, we documented the patient’s story, any pertinent medical history and/or family history, the physical exam, our assessment and the plan (better known as a SOAP note). This was a short, succinct and usable communication device (assuming you could read the doctor’s handwriting). Today’s physicians, in the hopes of better compensation, pull in every possible bit of information into the note including their great great great grandmother’s penchant for getting hangnails. OK, that’s hyperbole, but it is almost that bad. And then complain that the EHR is a terrible way to communicate and that everyone else’s notes are too long.

Having been the “champion” for the EHR in our system I have a request to make — Hide, or have your assistant hide, all that past medical history. You didn’t put it in your paper note and IT DOESN’T NEED TO BE IN YOUR ELECTRONIC NOTE EITHER. If it’s a matter of training or you don’t know how to take it out, please ask your friendly IT trainer and they will gladly help you.

There, I’ve said it and I feel so much better!

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Living with the Line

My home and office is full of art work done by the artists I have lived with over the last 30 years. My husband makes wonderful creations out of glass.IMG_4983




My younger daughter paints Georgia O’Keeffe-styled paintings for gifts and designed a beautiful canvas that sits behind my desk at work. IMG_1215


My older daughter designs programs for her medical school class and cards for her grandmothers. As a gift to me she drew a family portrait that captures each family member’s special character. IMG_0722

Surrounded by this talent, about five years ago I began to draw, hoping to do it well enough that my sketches would be recognizable in my journals, especially with travel. It’s been a slow painful journey but recently I began Sketchbook Skool, online classes founded by Danny Gregory, an artist I’ve admired for years. The first class began with an intimidating assignment – draw with a pen. The purpose of the exercise is learning to “live with the line”. Multiple times in the last six weeks I began a drawing and wanted nothing more than to tear it out of the book, get rid of the line and start the sketch over. But I had to persevere and since it was an assignment I kept working with it. Amazingly, as I continued with the drawing it would take shape and become something I really liked. My mistakes were not only livable, many times they were my favorite drawings when finished.

Porch Wall Hanging

Porch Wall Hanging


There are corollaries to be made in healthcare–perseverance for example, of which most family practice doctors need a healthy dose of every day. But the acceptance of imperfection, is that even safe in medicine? How do you accept, even more, celebrate the difficulties of practicing medicine today, especially in primary care? With drawing it’s a matter of going beyond ignoring the line–it’s using it to “bend” the reality of a picture, thereby creating something that resembles the object but is different, still recognizable but different. The corollary in my practice is helping patients become participants by using tools like social media, whiteboards and smart phone apps. But I’m an apprentice artist compared to the DaVincis of medical care:   The DPC movement with physicians like Dr. Robert Lamberts, and models like Turntable Health are “bending” healthcare practice to create better care for patients, and in the doing, taking physician practice to a point where it once again feels like Art.





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