A * Readable * Usable * Patient Note

It’s not just the clicks. It’s creating a Readable.Usable.Note.[1][2] It is embarrassing to look at a patient chart and read: “Your HDL (good) cholesterol is excellent but your LDL (bad) cholesterol is too high. I would recommend trying to reduce sure fact food intake.” What? Oh, yeah, reduce your fatty food intake. Or worse: “She wanted me to know that she had a laparoscopic hysterectomy and in for reck to me over the summer.” That one took a while to figure out. What I dictated was “she had a laparoscopic hysterectomy and oopherectomy over the summer.” Ouch. I read over my notes before I sign them but between the rush of seeing patients and the problem with editing your own notes within the horrible output that electronic records produce, it’s easy to miss your own mistakes.

The notes are built to maximize the billing that we do. But frankly, even though I revisit a patient’s chart and check their past medical history, update their meds, update their family history, review their social history, etc. IT DOESN’T NEED TO BE REPEATED IN THE NOTE! However, if I don’t rewrite all that, Medicare or the insurance company doesn’t believe I did it and I can’t charge for it. As a consequence everything is repetitive and finding the little gem of information one needs to care for the patient becomes more and more difficult. As anyone who has ever received the reams and reams of paper from an ER with an electronic health record (EHR) that has no discernible font changes or indentation can tell you, it is next to impossible to determine why the patient was there, what treatment they received and what followup they need.

To counteract this I dictate my medical reasoning in the discussion box at the end of the note. Next visit that’s where to look to find the important stuff. Of course this increases the amount of time documenting, taking away more precious moments I have to spend with the patient creating inelegant notes that are one step away from being worthless for subsequent treatment.

What if we could create two notes for every patient. One that went in to the billing records for auditing purposes and one culling the important stuff into a true “patient care note”. Surely there is software that could help us with that.

To quote Dr. Vartabedian: What do you think?

1. We need to reassess the patient note. http://www.kevinmd.com/blog/2013/08/reassess-patient-note.html
2. The doctor will see your medical record now. http://www.slate.com/blogs/future_tense/2013/08/05/study_reveals_doctors_are_spending_even_less_time_with_patients.html

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Price Transparency in Medical Care

As healthcare costs become a bigger and bigger chuck of our Gross Domestic Product (GDP), price transparency is a subject that insurance companies and patients are talking about. The idea of knowing how much something costs, be it canned black beans in the grocery store or replacing the leaking faucet in your kitchen, seems obvious but it will be an uphill battle to enact change within the healthcare system. The concept seems simple–make prices accessible to the people who are paying them just like in any other service industry. While healthcare is more complex than a plumbing job, there are still some things that should be easy to price–cataract extraction, blood pressure check, yearly physical, uncomplicated appendectomy. The hidden prices and unknowns in medicine can quickly add up. It is no wonder that  patients are angry, frustrated and incredulous.

Case in point, my mother called yesterday to ask why she was not told that going to a cardiologist in our system for a test was “outpatient treatment” in a hospital. She had no idea that was the case until the  EOB (Explanation of Benefits) came from her insurance company with a charge specifically associated with that. The answer is that the cardiologists are employees of the hospital so there is an additional fee tacked on to her bill. Even though her visit appeared to be in a doctor’s office, it is now an extension of the hospital. As such they tack on a “facility fee” that, while technically allowable, I find distasteful and misleading, even as it is done by my own healthcare system. Talk about a lack of transparency! My mother had no clue and at 84, even if someone did explain it to her, I doubt she understood what they were talking about. Not until she got the EOB from her insurance company did she start to question.

A patient with congenital heart disease told me this week she was putting off getting an imaging study on her heart because she can’t afford the $1000 hospital fee that her now-hospital-employed physician would be adding to her bill. One thousand EXTRA billed dollars solely for that reason??? How do hospitals justify this? They state that patients are paying for the “added services” that being a hospital-associated facility affords them, like infection control and patient safety. I doubt anyone thinks paying four times what the doctor charges for a facility fee is justified by patient safety. For another take on this please read: Medical Billing: a world of hurt.

It’s encouraging to see patients becoming more involved in this process–pushing for price transparency[1]. Doctors are also beginning to understand that we can no longer hold ourselves above the fray, believing that caring for the patient in the best manner possible without knowing the economic burden that care incurs to the patient or family is not our concern. Best care does include knowing costs. In the meantime, my patient who needs the echocardiogram waits, and hopes for the best.

1. Outofpocket.com. Lori, Mona. Frisbie, Patrick. 11/07/12. Flying Aces Incorporated Inc. 11/10/12 http://outofpocket.com/Blog/2012/11/07/TheBiggestQuestionNoOneIsAskingInHealthCare.aspx

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