All the patients in my office who were inconvenienced yesterday deserve my thanks. They endured long processing times and our somewhat distracted visits with grace and good humor. They should be rewar…
Second day of Epic training went well. We were taught Inbox processing and how to interact with the patient portal. This was miles more straight forward than documenting a patient encounter. The follo…
"Ambulatory 100" went well. The trainer, Joel, was knowledgable and went through a reasonably accurate episode of care with a patient. I think I can write an adequate note today IF the problem was not…
In the last week I have received three documents from hospitals that illustrate what physicians find so frustrating about the MU (Meaningful Use) program.
Example #1: Patient’s wife calls me for an appointment regarding three episodes of passing out. On obtaining the emergency room records there is no mention that the patient lost consciousness. In fact, there is no story whatsoever regarding the patient’s presentation or symptoms. All that is in the document is lab values. I can tell that the ER physician evaluated the patient for a heart attack which is not a typical workup for passing out.
Example #2: Patient presented to the emergency room with shortness of breath. As far as I can tell she was given four nebulizers (breathing treatments) and sent home with no new medications or orders. What?
Example #3: This was a discharge summary following hospitalization. It lists the patient’s allergies, lab reports, radiology tests and medications but yet again, I don’t have the patient’s story or the other physicians’ thoughts on how treatment progressed and how the patient did, in other words, the narrative that physicians use to communicate with other physicians is completely missing.
After receiving those documents early in the week two more were faxed. Thankfully, these give me a Paul Harvey “rest of the story”. So how is this meaningful? The information I need to care for my patients was not contained in the first documents whose sole use is to fulfill meaningful use requirements. I am forced to look at two documents when one would not only suffice but actually be helpful. This wastes my time in an already time-stressed schedule. It is neither meaningful nor useful.
Patient brings in two sheets from Caremark. They recommend that she discuss blood tests with her doctor because of some meds she is on. One of the medications is a non-steroidal anti-inflammatory (NSAID) and the PBM (pharmacy benefit manager) recommends that she have LIVER function tests checked by her physician. Now kidney function abnormalities are many times more worrisome and common than liver problems with the NSAIDs. I have multiple patients in my practice with significant kidney damage as a result of NSAID use and I have never seen, in many years of practice, liver damage, though I know it is theoretically possible.
Seriously…when can we get the insurers and the PBMs out of the exam room so I don’t have to spend more time discussing issues that are not a problem, instead of the issues that we need to talk about?
Patient goes to Walgreens to have her lipids and glucose check. The lab work is sent to me BURIED in a four page “EHR” note. So useful. It’s not discrete data so I can’t compare it to previous blood draws and it is difficult to find the labs. I have to click through and scroll multiple pages to find it.
THIS IS NOT INTEROPERABILITY! This is minimally useful. At least if the patient had come in my office the labs would be discrete and we could easily compare the data from year to year.
Scrolling through my morning feed I happened upon this article about a physician’s suicide: Doctor’s Death an “inconvenience”for patients. Suicide has become an epidemic among physicians. Blog posts are rampant regarding this fact and most suspect that the loss of respect and control physicians have experienced in their careers over the last thirty years contributes mightily to the despair of practice.[1,2,3,4]
The callousness apparent in the article reminded me of less horrendous, but similar instances in my own practice and stories from other doctors who have taken vacation or had to reschedule patients due to unforeseen circumstances. I have been upbraided by patients who wanted to know why I had the audacity to spend time with my family or take a personal day when they needed to see me. This is amplified by my new contract which features “allowed time off” instead of “paid time off”. Not only do patients not value the time I need to replenish, but my system punishes me for doing so. If I never take time off, then I make more money for them and me. The importance of play in innovative thinking and better patient care is forgotten in the greed of corporate money-making.
As my daughter enters the arena of healthcare as a third year medical student, I hope the joy in patient care outweighs the sometimes callousness of corporate and patient expectations.
My ongoing regular posts regarding the daily aggravations and irritations of being a PCP.
Remember the Prior Authorization that I requested for my patient who had been on multiple anti-arrhythmics and saw a cardiologist who, after trying other medications, put her back on just digoxin and said to keep her on that? — Irritation #1– Well, Cigna decided, because apparently they know more about cardiology than the cardiologists and specifically they understand treatment of the individual better than a cardiologist who evaluated her, that she does not need the digoxin and refused the prior authorization.
REALLY? REALLY? Now my staff and I have to try to get her an expedited appeal.
It seems like every day some entity wants to question my medical judgement. I am not a perfect doctor but in the grand scheme of things, I know my patients’ health needs better than their insurance company, the government, or their employers. The constant interruptions by individuals who want to believe their algorithms fit every patient does little to serve patient care and much to reduce my efficiency. To make a point of how often this occurs, I’ve decided to TRY to document each interruption, within the confines of my limited time. Here is todays irritation:
PBM (pharmacy benefit manager) requires a PA (prior authorization) to refill digoxin. Patient has been on digoxin forever. It is a med that is rarely used anymore, though was once commonly prescribed for congestive heart failure or rhythm control. Unfortunately it has some negative side effects and typically there are better drugs for the conditions it is used to treat. However, in this case, patient came to me on digoxin. I sent her to a cardiologist to see if she could substitute another drug. She was intolerant to other medications and ultimately the cardiologist felt that digoxin was the least risky choice and continued it. This was last checked as recently as two years ago.
For those of you who are not geeks, or not healthcare geeks, I have spent the last week in Chicago at the biggest HIT (Health IT) “geek-out” in the world. Some 42,000+ people gathered in Chicago for the annual HiMSS (Health Information Management Systems Society) meeting. It is truly an overwhelming experience. On the first full day of the conference I got lost twice. Not an auspicious start.
As a member of the Connected Patient Committee for HiMMS, I participated in the Patient Engagement Symposium which brought together individuals passionate about using HIT to improve health in patients and communities. ONC representative Lana Moriarty (Office of the National Coordinator) spoke to the government’s goals along these lines. E-patient Dave Bronkart, a celebrity among patients passionate to change our healthcare system into a patient-centered and patient-empowered one, came to watch his personal physician discuss changing care models and shared decision making. Amy Gleason of CareSync presented the patient’s viewpoint when it comes to dealing with multiple portals. The highlight of the day was a call to action, voiced below in the video by Regina Holliday, well-known advocate for patient access to medical records. The “call” was made by Dr. Farzad Mostashari, former National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services. On the day before the conference began, CMS (Center for Medicare Services) proposed dropping the Meaningful Use (MU) requirement in Stage 2 (of three) from 5% of patients being able to view, download or transmit their medical records to ONE patient. Most individuals in the patient advocacy arena feel this proposed change sends a message to health systems and providers that patient access to their records is either no longer a priority or special interests have pushed this change of heart. This seems particularly odd in an environment of increased encouragement of patient involvement in their own healthcare. Dr. Farzad, e-patient Dave, Ms. Holliday, and myself are just a few of the many individuals who think this is the wrong message to send. As a consequence a Day of DataIndependence on July 4 has been declared, and patients are asked to request electronic access to their medical records by calling their physicians and hospitals and asking for their medical records in electronic format.
If access to your medical records, or your family’s medical records, is important to you (and it certainly should be!) watch this space for more information in the next few weeks. For information from the Society for Participatory Medicine regarding this issue, follow this link: No MU without ME.
Laying in the recovery area I sneezed, hard, five times. My right nostril burned. I pulled the oxygen off and asked my husband what the O2 measurement showed on the monitor above my head. “94% – it just dropped 3%”. I took deep breaths and the number popped back up. As my nurse walked into the room, I requested removing the oxygen measuring device from my finger. She said “Let me get one more set of vitals”. I sneezed a few more times, my nose running and burning.
Coming home that afternoon after my colonoscopy I continued to sneeze, the burning sensation in my right nostril got worse and the runny nose persisted. It was time to do what any competent physician (or e-patient would do) – I googled it. Apparently this is a common problem after colonoscopy these days. It turns out that with the addition of using propofol for colonoscopies, anesthesiologists insist that a high flow rate of oxygen be used during the procedure to reduce hypoxia (a low oxygen level) and the use of capnography, or measurement of carbon dioxide retention. In order to do this, as best that I can ascertain, they pump oxygen in one nostril and measure CO2 in the other. That’s a lot of hi-flow oxygen going into one nostril through a nasal cannula. There are studies related to the irritation this causes in patients as well as a reduction in patient satisfaction. It’s day three after my colonoscopy and I am still sneezing, my nose still burns and I still have a fair amount of rhinitis. Yeah, I’d say that’s a dissatisfier.
Just a heads-up to my patients about to undergo your routine endoscopy. The misery may not end once your bowels are back to normal. Take plenty of kleenex.
1. Li N-L, Tseng S-C, Hsu C-C, et al. A simple, innovative way to reduce rhinitis symptoms after sedation during endoscopy. Canadian Journal of Gastroenterology. 2011;25(2):68-72. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043006/
HIPAA (Health Insurance Portability and Accountability Act) was created in 1996 to protect patients’ personal health information (PHI) in addition to other things. One of its most frequently misunderstood sections involves the release of medical information. Although it specifically allows for treating physicians to access their patient’s health information in order to provide continuity of care without needing a patient to sign a release form, it is not unusual for this to be a problem. My office has had difficulty receiving necessary records from specialty offices and hospitals. Recently one of my patients was seen in a Kroger Little Clinic where she was treated for a urinary tract infection. Since her symptoms persisted, I needed the urinalysis from the clinic in order to determine future therapy. You’d of thought I was asking for gold from Fort Knox. In my long association with HIPAA I have found it mostly intoned by medical office individuals who have been poorly trained by the entities that employ them. Kroger has not appropriately educated their staff as to the ins and outs of a complicated law, thereby bringing about the following exchange on Twitter:
Ultimately I was able to get the UA results, begrudgingly, from an NP who I know called me a bad word as soon as she got off the phone. She was right. By the end of the day, I didn’t care what she thought of me. Just give me my patient’s damn data!
Flying home from the first HIMSS Patient Engagement summit, I finished Atul Gawande’s book, Being Mortal. I found myself aggregating my thoughts on the conference and the book. They both highlighted how slowly medicine embraces change as we struggle to put patients at the center of the healthcare stage. My reflections revealed that as far as I’ve come, I’m still not there in many interactions with patients. It’s still difficult for me to be more than “Dr. Informative”, which is Dr. Gawande’s accurate portrayal of physicians who are uncomfortable with medicine’s previous paternalism but unsure how to unravel the patient’s goals. During the conference patient panel, Kym Martin, a patient experience expert and four-time cancer survivor, commented that health is not just about the disease process. Physicians, indeed healthcare as a system, must consider a holistic picture that includes financial status, relationships, family support, work issues, etc. Present provider and hospital goals seem to concentrate efforts on what what we, the system, identify as the patients’ goals. Those “should bes” in our eyes are often not the reality of a patient’s existence if all circumstances are taken into account. Dr. Gawande struggles to remember to ask the following of his patients: “What is your understanding of the situation and its outcome? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?” And while his book is concentrated on end of life decisions, isn’t this true for all our patient interactions? Then at 10,000 feet over Chicago it occurred to me–wait, this was what I was taught a million years ago in Family Practice residency–to understand the patient and all that individual has to deal with, not just the disease AND to guide that person through the tangle of the healthcare system. Now if someone will just tell me how to do that in the seven minutes I have with them…