PookieMD's Blog: Where Physicians Learn About the Business of Medicine

Just when you thought you had it down, you need another skill set–legal eagle.  Untangling the proposed rules by the CMS for meaningful use of EMRs is a challenge that would best the best of ‘em!  Here’s a quick and dirty take on the latest rules set out by the Center for Medicare and Medicaid Services EMR Incentive program, from Jan 13.

Points of interest:

• sections apply to both inpatient and outpatient providers/hospitals.
• EMRs must contain problem lists which CMS notes : “Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®. We believe the term ”problem list” requires additional clarification. We describe a ”problem list” as a list of current and active diagnoses as well as past diagnoses relevant to the current care of the patient. “
• EMRS should contain active medications
• EMRs should contain active allergies
• EMRs should have CPOE (!)
• EMRs must note if a patient smokes(amongst other requirements.)
• Patients must have access to copy of electronic health record
• Providers must have a way to share electronically with other providers.
• Providers will get incentive money based on the percentage of medicaid/medicare charges submitted by the physician.  Therefore, if you have a high percentage of medicare patients you will get more incentive money.

Wow! The last two requirements open a huge can of worms: the questions of  interoperability (how to share a record with a provider that doesn’t have the same EMR) comes up, as well as concerns for patient privacy.

What would I do if I was in the market for an EMR? Honestly, I would carefully examine the amount of medicare/medicaid patients my practice has.  If I had a large amount of these patients, and actively saw them, it may be worth while to go after incentive money to get an EMR.  However, if you have a small population of these patients, your incentive may be little to none. The entire program is slated to go away in 2016, with decreasing incentives available each year.  However, the incentives don’t get smaller until 2012, so it would pay to be diligent in researching your population and careful in your selection of EMR.

The CMS rules were tough reading.  Please let me know if you have a different interpretation!

Click here for the  link to the PDF from CMS.

My parents are both over the age of 65 and recently retired.  They are now on medicare, and have supplemental insurance as well.  Both have some health issues and have long term relationships with their doctors.

Well, not anymore.

The large Medical Center that services most of the well heeled, small city where they live doesn’t accept medicare.  Patients may continue to see their doctors at the Medical Center once they turn 65, but 15% more is added to the bill, and the patients are expected to pay in full at the time of service.  The Medical Center will not submit claims, or do any paperwork on behalf of the medicare patient.  Getting payment is the responsibility of the patient once they are lucky enough to be on medicare. As you probably have guessed, most patients can’t afford to do this and seek care elsewhere.

The closest place to get care is another city, approximately 20 miles away. There, the physicians take medicare.  Most of the physicians in my parent’s city are employees of the Medical Center, and the Medical Center has enough non-medicare patients and doesn’t feel socially responsible enough to take in a portion of medicare patients.  Basically, the Medical Center has a monopoly as  most of the city’s physicians are employees, and the Medical Center’s position is of profitability at all costs.

The Medical Center has a stranglehold as most physicians are employees, and the city’s urgent care centers are owned by the Medical Center. The Medical Center, by turning away patients once they turn 65, demonstrates the worst model of profit driven behavior in the medical world.  Rather than accepting a certain percentage of medicare patients, which is what most socially responsible physicians, the Medical Center forgets they are in the socially responsible business of health care.  They elect to dump patients on the physician groups who are socially responsible.

I don’t think I would go so far as to mandate that physicians must accept a certain percentage of medicare patients.  I think this would be akin to forcing car dealers to accept less for a car from those over 65 years.  Instead I advocate that medicare reimbursement increase to fair market levels such that physicians are not forced in to dumping long term, long standing relationships in order to keep the doors of their practice open. And to the CEO of the Medical Center, I say–how do you sleep at night?

PS: out of respect for my parent’s privacy, I have deliberately not named the city where they live.  I wish I could have, as I think this would have more impact.

It may seem crazy, but now is the time to start planning for the economic recovery. There are bargains to be had, talent to be found and the sun will be coming out soon!  (I hope!)

So, a few tips on what to do now, to make tomorrow rosier:

• Invest in technology.  This may be the time to get serious about an EMR, especially with the government mandate and “reward” system.  (See previous posts.)  This is also a great time to launch or update your website, improve your billing software, etc.  (My company, ExtraMD is upgrading our computerizedreservation system so clients can get faster reservations and confirmation when booking one of our “local locums” doctors.)
• Get good help, cheap.  There are lots of  job seekers out there.  Make sure you take the time to search for the diamonds that are sitting in that resume pile.  Now’s your chance to get some great employees!  Don’t simply hire the first person that comes along–do your homework!!
• Train like an Olympian–invest resources in training employees(and physicians!) on that new EMR.  And for pity’s sake if everybody needs ACLS, or BLS, now is the time to get it done!
• Analyze cost cutting. You may have made across the board cuts, and it’s a perfect time to review  them. Continue to reduce spending, but not in ways that limit growth.  Look for ways to permanently cut costs. It’s easy to ignore costs in good times, but smarter to make long lasting cuts that will continue even in better economic times.
• Fix the bottle necks.  Analyze your work flow, and see what needs to be done to improve through put.  Would another copier help? An office redesign, another computer?  Seize the moment to bargain hunt for items that will have big impact in improving your practice. 

If you can afford it, now is the time to invest in your practice!

• Hospital called to see if I could come in 'cause their swamped. I fell bad saying no. And what do you do when your partners are swamped? #

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This post borrows heavily from Attitude is Everything, especially chapter 9, by Keith Harrell.  The names have been changed to protect the innocent.

I am going to propose that there be a new ICD-10 code  for e/m of “changitis: the fear of change.”  (Don’t bother looking in the DSM for this!) Anyway, my hospital is going through a change with their EMR–a huge change, but inevitable.  I have observed the following  attitudes and behaviors from the physicians with whom I work:

Dr. Ostrich: “It won’t effect me because I never used the key functions anyway.” (Denial and as Harrell says, “a shift into neutral.”)

Dr. Eyeore: “This is horrible.  How could they allow this to happen? What’s with these people?” (Adopt a negative attitude.)

Dr. Wily Coyote: “Let’s start a revolution! Rally the forces! Ready the weapons! Let’s do everything we can to stop the change!”  (Adopt a counterproductive attitude.)

Dr. Welby: “Let’s make the best of it.” (Adopt a positive attitude.)

I learned something about change management from Mr. Harrell’s book.  As we all know, EMRs will become more prevalent, with the government mandated stimulus package to move medical care providers to use an EMR.  We can either cope effectively, or plan for an early retirement. Harrell suggests that we may not be able to prevent a change from occuring, but we can take positive action and make the most of it. We should acknowledge change, and seek to change threats into opportunities. So, when that EMR or new practice methodology or latest study on statin causes you to change the way you practice, try to embrace the change and make lemons into lemonade.  (Actually, make lemons in to margaritas!)

Photo

I’m part of an effort to deploy an updated version of my hospital’s EMR.  It will be no small feat, as changes, they are a coming! There appears to be a smack down in the making over…(drum roll!)

The problem list!

One faction thinks that the problem list should contain, well, problems! This same faction also thinks that past medical history belongs in (I blush to say it!)…past medical history.  Ditto surgical history and family history.

The other faction believes that everything should go under the problem list, sort of a one stop shop.  They claim that this is one place where providers can get all the information they need, and that they shouldn’t have to update past medical history and the like.

Osler would role over in his grave.  What happened to the adage that most of the diagnosis was in the HPI and history?  What happened to the fact that past medical history was used to help diagnose and prognosticate? What happened to the fact that problems were things that clinicians were actively working on, and that past medical history was the past?

Putting everything under problem lists makes for muddled thinking and even worse, poor care.  If we can’t keep our thinking straight, than caring for a patient is all that much harder.  EMRs are only as accurate as their users.  If we can’t get it right in the EMR, it will perpetually be wrong.

Sorry, but it smacks of laziness on the part of providers not to populate past medical/surgical/family history. It is still an important part of patient care!

What do you think–do you take the fewer key stroke way (read lazy!) or do you go the distance?

If you’re a typical doctor, you are constantly reading.  The doctor business seems to select for those of us that love to read and learn.  Recently, I felt that a lot of what I read wasn’t sticking–my brain was like rubber and everything just bounced off!  I have been rereading Love is the Killer App, by Tim Sanders, and his chapter on knowledge was striking–yes it finally stuck to my brain!

He suggests that we should read constantly (got that down!) but not just read, but consume and digest.  He says to highlight relevant sections, and write important points on the front cover.  He also suggests we talk about what we read, and that the more we talk about the book, the more we will learn, and the more able we will be to share our knowledge.  He suggests that we hang out at bookstores (truly one of my most favorite places!) and fill our plates with all sorts of books, searching for titles based on key words from topics we are interested in.

Sanders also instructs us to try and find the “Big Statements” of the book–those sentences that summarize and crystallize the message or lesson of the book.

My personal bent is to carry around an index card and highlighter (one that is not dried out!), and make notes on the index card and highlight the heck out of the book. Later on I file the card.  I keep a bunch of blank index cards in my brief case for this. (I have to hide the cards at home because Tweenager Daughter is always taking them!)

So, don’t just read–consume voraciously and digest throughly!  It’s what the doctor ordered.

Quote of the day: “If a man is called to sweep the streets, he should sweep streets even as Michelangelo painted, as Shakespeare wrote poetry, as  Beethoven composed music.  He should sweep streets so well that all the host of heaven and earth will pause and say, ‘Here lived a great sweeper who did his job well.”–Martin Luther King, Jr.

A good friend loaned me a book called The Information Cure.  It is written by Jeff Margolis, who is the CEO of the TriZetto group,  which provides “enterprise information solutions to U.S. healthcare payers.”  (I’m not sure what this means.)  However, there is was an enlightening section on how insurance companies view physicians and health care providers when a patient status post hip replacement gets what appears to be MRSA.

Mr. Margolis faults the hospital for the infection. “If the hospital had known in advance that it would be paid only for the original planned hospital stay and hip replacement procedure, would that have made the hospital more likely to follow evidence-based medicine protocols?  What if we paid doctors and hospitals for the procedures they were supposed to perform in the first place and not for the care that resulted from medical?”

The view is that infections, errors and bad outcomes occur because physicians and hospitals get paid more if there are complications.  He makes the case that we don’t pay attention to details such as clean hands because we don’t get dinged monetarily for infections, rather we are “rewarded” by making money off of complications.  Margolis claims that if we were paid for performance we would rapidly eliminate errors, infections and bad outcomes.  He completely disregards the fact that things go wrong, in spite of our best efforts.  He implies we are only motivated by money, not that we personally care about the health of our patients.

It is sad how easily we distrust each other.  The insurance industry so easily points fingers at physicians,  claiming that rising health care costs are the responsibility of the germy, unclean physicians that care not a whit except for the money earned, and that physicians greedily anticipate making more money from the complications they so easily induce.

Don’t get me wrong–many errors and bad outcomes can be avoided with proper procedures.  But to think that physicians care not about bad outcomes is ridiculous.  Yes, we care about the bottom line, but more importantly, we really do care about our patients.

I just finished The Checklist Manifesto, by Atul Gawande, and it is a must read.  Checklists are making their way in to medicine, particularly in the area of surgery.  Dr. Gawande is a surgeon, and most of the anecdotes in the book are surgical.  As an internist, I have struggled to find a way that checklists can make an impact and improve my practice as a hospitalist.  Most of the current checklists are oriented toward procedures, and as an internist, most of my time is spent thinking about patients, rather than doing a procedure.

However, the chapter titled, “The End of the Master Builder,” was worth the cost of the book.  In this chapter, Gawande examines how a sky scraper is built.  He notes that there are multiple check lists developed by each of the trades involved, and milestones that must be met before the next step can be taken.  He explains  that originally there was a master builder that would design an entire structure and supervise the building of that structure to completion.  However, today’s building are too complicated for one person to know everything about how to build a sky scraper.  Hence, the demise of the master builder.  Gawande states that physicians view themselves as a master builder (the “Master Physician”), but argues that technology and the human body are just too complex for this to be an effective way to heal people.

Instead, he notes that the building industry also has a communications check list.  This is a list of which contractor should talk to which and at what time to guarantee safety of the building at each step.  This was striking.  I have been analyzing what makes difficult medical cases go well and go wrong, and I found that a key item was communication (or lack of) with subspecialists helping manage the patient.

So this week, as part of check list I use when I am rounding, I put “cons” for consultant by each patient name.  This was a way to remind me to 1) call a consult if needed 2) speak to the consults on the case.  I think we are relying too much on written notes, and not enough on verbal interactions to discuss care and management of patients.  My deliberate efforts made me feel that I was delivering better, more cohesive care.  None of the subspecialists appeared annoyed or upset that I was taking more time to talk with them.

It was an unscientific test, but I think we (Gawande and I!) are on to something.  In this complex world of medical care, we need to hone our communication skills and standardize them.  Now, I just need to design a study supporting communication check lists, and get buy in from the physicians where I work…

The new year brings the January slowdown, in which patients don’t come to the office for appointments because of many reasons–most of them financial.  Lots of patients have huge deductibles, and will have to pay for every bit of their health care until it is met.  Other patients are tapped out from the holiday season, and are now looking at big debt.  So how do you encourage patients to come in and get the health care they need?

For new patients, make a big deal of the first appointment.  Send out a packet ahead of time, with your bio, as well as information about your staff, office info (where to park, hours, services), and forms to be filled out.  Include  payment policies. Also include a health “tip sheet”–e.g. reminders that exercise, prudent diet, proper medical care and non-smoking offer big health dividends.  (Yes, dear readers, of course you should already have all of this on your website!)  Include your card in the packet.

For established patients, send a reminder post card, and emphasize the necessity of continued medical management for continued health.  Make the postcards up beat, and again offer a health tip.  You don’t need to do postcards every month, but January is an especially good month to get everyone started on their new year’s resolutions!  Postcards should include contact information so patients can easily make appointments!  You should always have staff call and remind patients of their appointments 24-48 hours ahead of time.  There are automated ways to do this as well.

Consider offering something free–a noon seminar on healthy eating, or ways to include exercise in a daily routine.  One of the most fulfilling seminars I did was a diabetic teaching seminar, complete with lunch and samples.  I paired up with a nutritionist, and a drug rep bought a light lunch for the group.  It brought huge kudos and loyal patients in to the office.

Make the experience enjoyable.  Your receptionist should greet patients cheerfully, your office should be neat with up to date magazines, and for pity’s sake don’t keep patients waiting!  Have the patient make their next follow up appointment before they leave the office.

Develop a quarterly newsletter.  This is a chance to send out information on medications, immunizations, new staff, and encouraging news.  Newsletters are a way of attracting the type of patients you want to see in your office–and beginning to build a practice that you love.

Make it happen!