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

Most physicians, sometime in their career, end up becoming involved in some way with administration, whether running a practice or taking on some sort of leadership role at their hospital.  Such is the case with me, as I am heavily involved in a large change coming with the EHR that my hospital uses.

The one thing I find foreign is the amount and length of meetings that I go to.  One trait (a good one!) of physicians is the belief that we must get things done.  We are trained early on that if we don’t make something happen, it doesn’t happen.  In addition, we are held medically and legally responsible for things that don’t get done.  That’s enough to motivate just about anyone, and gets magnified in the usual type A, driven, get-things-done physician.  However, meetings are a dangerous place for such driven physicians.

Some meetings can suck you dry like a thirsty vampire at a blood bank.

Meetings can be divided in to 2 types: the “informational” meeting, whose abject purpose is “share” information so we are all “on the same page.”  These are the meetings that run the longest and seem to be the least productive. At these meetings you are  likely to encounter a species of meeting goer–Humanis chatterbox.  This meeting goer loves to hear himself speak.  And sadly, physicians seem to be a large percentage of this sub-species.  Favorite saying, “In my experience….”

Other meetings are the “solutions” meetings.  At these meetings, solutions are to be developed for problems.  This meeting is the purvey of another species–Humanis negativus.  This species has a rubber stamp that gets hauled out and used at every opportunity– the “NO” stamp.  Favorite saying of this subpecies? “Just say NO!”  Profession most likely to be represented by this species? The lawyer.

Of course, no meeting would be complete with out the technical folks.  This species–Humanis technacus, speaks a language most of us don’t understand.  They speak a language called “information technology” and use words like “interface”, “mapping” and “HL7″.  They love their product, the EHR, and frequently forget that it is a tool for care, rather than the end product.  Favorite saying? “But look, we just built this and it’s so cool!”

My advice, when attending these meetings is several fold:

1. Be grateful that you are a doctor, so when you go back to your practice you can glory in feeling of getting something done!
2. Bring a giant latte so keep you in the game.
3. Realize that good results and ideas do come out of these meetings, but just not at the speed you or I are used to.

Talk later! I’m off to get a cappuccino before my next meeting!!!

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This year has been the year of information technology learning experiences.  My web site has undergone a major upgrade (which is still not live!), I bought a new cell phone (a Blackberry, which I love), and one of our office computers suffered a major meltdown complements of McAffee. Here are lessons a non geek doctor has learned (so far!) from the wonderful world of information technology:

1. Pick two of three: good, cheap or fast.  I am trying to get an online reservation system built for my website (www.extramd.com) so our clients can request physician coverage on line.  We started the project in January, with the idea it would be running by the end of February.  It’s still not fully operational.  The person I have doing it is good and cheap, but not fast.  I’m a small business owner, and I trully believe you can only afford  two of the three. I elected for for cheap and good, but I don’t know if this was the right choice.
2. Don’t listen to teenage salesman when it comes to cell phones.  Last December, I listened to a youngster at the phone store, bought in to the hype and bought a Droid phone.  What a mistake.  Nothing on it that was actually useful.  It had all sorts of “aps” you could put on the empty phone, but after I calculated the cost of loading up the phone so it was actually usable, I turned it in for a Blackberry.  Love the Blackberry, hated the Droid.
3. Antivirus programs aren’t that good, especially when they are the cause of a computer crash.  Last month, the main computer my company runs on crashed because of McAffee, the anti viral software the “protects” my computers.  McAffee had just released a new upgrade, and down went the computer.  After two days of trying to fix it, I took it to the computer doctor, who told me the upgrade crashed the computer.  I had just paid to renew McAffee on all the computers.  McAffee says it will make good on the repair bill, and will let you know when/if I get the check.  (My claim is “under review.”)
4. Have some sort antiviral protection however.  Entrepreneur magazine states that one third of small businesses have no antivirus software!
5. Don’t open emails that say “open here for free cash.”  I didn’t do this, but believe it or not, this is a prime way small businesses get attacked by viruses.  Some poor slob opens that email, and in marches the virus.
6. Back up your computer in multiple ways.  I like mozy.com which backs my computers up in to the “cloud”, and I also back up on to a flash drive.  You will still have to go through the pain of resinstalling everything if you do suffer an attack, but it’s better than nothing! A friend of mine had a disc drive failure and it still took her 40 hours to restore everything!

There are many more mistakes I’m sure I’ll make, but I’ll learn from them! Hope you can learn from mine!!

I was getting a massage yesterday, and it struck me how simple the payment system was.  I paid for a twenty minute chair massage, told the therapist “my shoulders really hurt,” and away we went.  He worked the knots out, and I gratefully sat there in quiet bliss, face smashed against a paper towel on the massage chair.  At the end I said thanks, and gave him a tip.  I didn’t stop as I stood up and say, “But you know, I really hurt in my low back. Can you work on that too?”

Instead, I put my money in the tip jar, and listened as he told me to drink lots of water.  What if doctors were paid that way? What if the patient paid for a certain amount of time, and when it was over, it was over?  If the patient wanted more time, she would have to pay for it.  For instance, if I had wanted him to work more on my shoulders, I would have forked over the cash. Also, I made sure I was ready to start and didn’t waste time chit chatting.  Imagine: the therapist asks: “Are there areas you want to focus on?” and I answer, “well, yesterday, I was playing in my tennis league, and was serving really hard, and then didn’t stretch afterwards, but instead went right to the beverage table, and had snacks–and they were really good, they had those wraps with the turkey and swiss, and ranch, and I really love them. And then I had a glass of wine, red, I think, and then some of those brownies…And so my shoulder hurt, because it started to rain, and I didn’t have my jacket and the car was too far away to make it work my effort and then–.” You get the point.

And if I had chattered on, he would have taken it out of my chair time.

What do you think? A new billing system in the works?

So you wanna have an EHR, do ya?  Well it’s not all about plug ‘n’ play, you know!  What does it take to successfully implement an EHR?  According to Biomedical Informatics edited by Edward Shortliffe (do not read unless you need to fall asleep!) there are five key factors associated with successful implementation.  Here they are, and I want you to look for the common theme.  Answer is revealed below!  (Hint: I added the italics.) According to Shortliffe, et al successful EHR imlementation depends on:

1. Organization leadership, commitment and vision
2. (the ability to) improve clinical processes and patient care
3. involving clinicians in the design and modification of the system
4. maintaining or improving clinical productivity
5. building momentum and support amongst clinicians.

Okay, so the quiz was easy. The bottom line to successfully implement or modify an exisiting EHR, you must have clinician buy in and support, and also improve productivity.   The ultimate bottom line: the EHR better deliver better patient care.

How’s your EHR stacking up?

My Tweenager Daughter has anaphylaxis to tree nuts, walnuts in particular.  Earlier this year she accidentally ate a cookie containing ground walnuts, and you guessed it, was as near to anaphylaxis as I want to see.  After skewering her with an EPI pen, tossing in the car after she vomited, I raced to my local Emergency Department, picking up a police escort in the process.  (I was speeding, and had no remorse. Give me the ticket, and I’ll keep my kid alive, thank you.  What was funny was when I finally stopped in front of the ED and my husband zoomed in carrying my daughter, the police officer said, “You know, ma’am you were speeding.  I could understand it if you were a doctor on the way to an emergency, but you were just bringing your kid in.  She’ll be fine.”  I  didn’t say a word.)

Anyway, we did the whole drill, with a second epi shot in the ED, steroids, pepcid, benadryl, blah, blah, blah.  She was fine and we finally made it home.  I was a wreak, but she was fine.

So last week, we were at her doctor’s getting a check up.  I asked if they had gotten any notification from the Emergency Department about the visit.  Nope, no record sent to the PCP. And yes, I clearly identified who her PCP was during the visit to the emergency department.

ARGH! What does it take to have us communicate effectively and efficiently with each other???!!! Peoples lives are on the line, and we have to do better!

PS: For those with nut allergies, ground walnuts are hard to see in cookies.  Ask you neighbors about such things when they bring you baked goods.  (It was a bad mother moment when I let my guard down and let Tweenager Daughter eat the cookie with out asking about nuts!!!) Be careful out there!

The hospitals where I work have 30% of the patients that have “no PCP”.  That is an astonishingly high number, and is probably not a valid number–patients may not know who their PCP) is, or nobody asked, or it was just easier to hit “No PCP in the computer”. But so what? Why should you care?

Because it really, really matters from multiple stand points if the patient has an identified primary care physician.  It matters because:

• Patients that have an identified primary care physician have a place to go after discharge to get on going care.
• As highlighted in JAMA May 5 edition, heart failure patients that get follow up with in 7 days of discharge have a 10-14% lower risk of readmission or mortality.  If you don’t have a primary care physician it’s hard to get early follow up!
• Hospitals will soon get “dinged” for readmission of Medicare patients with in 30 days.  If the hospital doesn’t find out who the primary care physician is, they just raised the risk that the patient may be readmitted.  It behoves the hospital (and hospitalists/hospital physicians!) to find out, identify and communicate with the outpatient physicians regarding follow up care.
• Physicians, both in and out of the hospital care because we want practice good medicine.

So, clearly, from a patient, physician and hospital perspective, having an identified primary care doctor who will manage care after discharge is paramount for the health of the patient, and the finances of the hospital.  (Let’s call it like it is!)

So what needs to go on at the discharge process?

• Communication between “sending and receiving” physicians (the discharge summary!)
• Medical reconciliation
• Follow up plan outstanding tests and ongoing problems
• Preparation of the patient as to what to expect next
• Signs and symptoms of worsening conditions.

How well do we do with this?  PCPs complain constantly that they don’t get discharge summaries in a timely fashion, or at all. This directly effects follow up of outstanding issues and problems.   Medical reconciliation is fraught with mistakes, especially with fragmented record keeping.  Lastly, the discharge instructions to the patient are frequently misunderstood or incomplete.

So here’s what needs to be done:

• Hospitals must start by ramping up efforts to identify and document who the PCP is.
• Hospitals must identify and implement easy ways to get discharge summaries and other reports to PCPs in a timely fashion.
• Hospitals and hospital physicians must find ways to reconcile medications through out the hospital stay, recognizing the most dangerous medication hand off is at discharge.  Avenues to be explored include fax, interconnectivity of systems/interoperability of systems, phone calls, emails etc.
• Hospitals and hospital physicians must establish processes to verify understanding of patients of discharge instructions of follow up plans.

Get out there and make it happen!

Today I was at one of my favorite sites on lifehacks.  There was a blog on the “10Tips to Create a High Performance Workplace”.  Me being the fun loving, efficiency afficiondo instantly started reading the blog.  So here is how my work place stacks up, and why I now have a really great excuse for low performance(!):

• “Clean”–sheesh, the card table with the two computers on it that the ED lets the hospitalists work at is covered with crumbs, coffee cups containing gel like brown material and used tissues.
• “Organized”–no organization here.   There is a stack of order sheets you can root through if you have the time.  Otherwise, it’s easier to print out your own.
• “Uncluttered”–see notes on food ditrius above, not to mention that there is no usable space–it’s all taken up by the computer monitors, the printer, and the random stacks of order sheets.  I frequently put my clip board in my lap ’cause that’s the only place left.
• “Walls painted a color–not white”–Ha, ha, ha.  The only color on the white walls is spatter from mysterious body fluids, whose origin I would prefer not to investigate.
• “Good natural light”–I have yet to be in an ED that has a window.  Were they afraid patients would escape out the windows when they designed the building?
• “Healthy live plants”–the only plants that are in the ED are the ones used for “medicinal” purposes, and they aren’t living–unless they survived their time in plastic baggies.
• “Intersting colorful art”–I guess the wall spatter could be an abstract painting of sorts…but the color scheme leaves alot to be desired.  At least in a primary care office they can put in some color and nice art work. Hmm, maybe primary care does have an upside!
• “Momentos that matter to you”–I don’t carry anything that matters to me in to the hospital for fear of losing it!

Wow, no wonder my brain goes to mush as the environment I work in is chaotic, cluttered, filthy, noisey and cold.  Seriously, however, I wonder if we would have better decision making and outcomes if our work environment was less chaotic (not to mention better behavior by some patients!)  I think a sunny yellow would pep me right up!

I like to fancy that I am a good doctor.  I know I am good at reading, and particulary like to read old charts of the patients I am about to see.  The two hospitals I work at have EMRs, as do lots of the primary care doctors whose patients I help care for.  (No, I’m not going to rant on interconnectivity, although it’s tempting.)

No, today I am going to rant on two things: admission history and physicals, and discharge summaries.  Much can be gleaned from them, and at my two hospitals both theH&) andthe discharge summarey are  part of the EMR, EHR. (I’ve been told to refer to the electronic record as the electronic health record from here on, so I’m retraining myself.)  Anyway, much is to be gained from reading the discharge that your colleague so dilligently dictated or typed.  Like, your patient who had “heart troubles” and had that “normal test” actually had a stent placed and was told to take plavix, which the patient never picked up because it was too expensive. (Admit, you have all had that patient!) So, just from reading a one paragraph summary, you figured out the patient has known coronoary disease, and is at risk for re-occlusion because he had never picked up their plavix.  You look brilliant, but you’re not–you’re just thorough because you took the time to read the notes.

I love being the hero, especially when all I have to do is read the chart.  These days it’s even easier to get reliable information.  In the age of electronic health records, there is no excuse not to know what happened the last time your patient was in the hospital.  So stop you whining about EHRs and look like a hero.  (Now, if we could only link all of our various EHRs together…but that would be Nirvana!)

• Great master mind group–topic: how much work is enough? When are you done? #

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In my last post, I was a bit dark with the factory worker analogy.  However, this is status quo for primary care.  But, given my promise that if I complain about a problem, I will seek to find solutions. So here goes:

Physicians must become leaders and team players.  Sometimes, when I am wearing my EMR consultant hat, I have to remind myself that I am not the boss, I’m a team member, and not necessarily the most important team member!  (I think we physicians love to be the boss–after I told my daughter what I did at work, she commented, “so basically, you bossed people around all day.”  Ouch!) Being the boss is not the same as being a leader!

So what’s a physician leader? Here are things you don’t hear from a physician leader:

• “That’s not how we do things”
• “We’ve always done it this way.”
• “I don’t have time.”
• “You can’t teach an old dog new tricks.”
• “It will never work.”
• “That’s of no benefit.” (I think this was heard at the introduction of hand washing and sterilizing instruments!)

So what are what does a physician leader say?

• “Show me the data.” (We love data!)
• “How we will do this?”
• “Does it improve patient care?”
• “How much does it cost–in terms of time, money and will power, and what resources do we have for this?”
• “Who can I work with to get this done?”

So if you really want to stop being a factory worker physician, get out of your silo. Learn to lead, not to boss, open your mind to new ways of thinking and doing things, and learn to collaborate. And lastly, listen much, speak little!