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

I wear many hats, and I suppose you do as well.  I wear my small business owner hat when I run/manage my company, ExtraMD, my doctor hat when I play doctor, and my consultant hat when I head off to multiple meetings that seem to define the EHR consultant world I live in.  Of course, I wear my mother hat, wife hat, Girl Scout leader hat, and the hat that seems to get worn the least–the self hat.

My biggest challenge is going from role to role.  It’s hard to switch gears when going from one area to the next. Here’s what I have learned (so far!):

• there is no such thing as balance. Accept that you will spend more time in any given role depending on the importance/immediacy of the project at hand.  (For instance: when I am seeing patients, everything else, barring outright family emergency, comes second.)
• everything is a project, and projects need to be divided in to action steps. 
• define to-do lists by action steps–example “call” or “email” are proper ways to head a to-do list.  “Decide” is not–you have to figure out what to do to help you decide something–do you need more information, to talk to someone, to get financial estimates? Break the item down into clearly defined verb oriented action steps.
• in meetings, I take notes, and on the side of the page, create “action steps” from my notes.  I have an action journal I got from behance that I love.  I then periodically go through the notes and make sure I have acted on the action items.
• put some items on the back burner, and keep a list of these ideas.  Not all ideas can or should be acted on at the same time.
• realize you can’t think of everything.  I have a good friend I talk to about my small business, and several doctors I run things by.  Still looking for someone to talk to about the consulting gig.

Would love to hear about things YOU do in your multiple roles!

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!)

I’m reading a cute book–the Happiness Project.  The author has a really fun part–her “12 commandants of adult living”  (or something like that.)  I got to thinking about my 10 commandments of physicianhood–in other words, rules to doctor by.

1. Patients die.
2. Doctors can’t save everyone–refer to rule number 1.  (Surprisingly a rule that I have struggled with as it seems as if this should be something I can do–what else did I train for?)
3. Ask questions, even if you think you will look stupid.  Don’t be afraid that others know more than you–they do, but you know more on other subjects!
4. Read as much as you can.  I have been trying to outline articles on index cards and filing them. No, I don’t think I will ever refer to them, but the act of writing stuff down helps me learn.
5. Have good friends that will watch your back.  We all need someone to bounce stuff off of, and to complain to, who will tell us that we are good doctors even when the chips are down.
6. Stay calm outwardly if possible.
7. Use this ridiculous stuff we experience to write a memoir.  (Someday I will tell you about the white supremacist, the acupuncture incident and the paralyzed guy who walked to his appointments.
8. Resign yourself to spending some long days, no matter how hard you try.
9. Experience is a good teacher.
10. No one but other doctors appreciate sick doctor humor, especially at the dinner table.

Full disclosure: rules 1 and 2 came from M*A*S*H–my most favorite TV show of all time!

Medical decision making grows more complicated daily.  Before we can even focus on the problem at hand, we have to synthezise data from many diverse sources–we use the old fashioned tools of listening and talking to patients and families, then log in to computers to obtain more data, view radiology images from yet another system, and call colleagues to discuss what we know or don’t know.

Whew.  Just the data gathering is complex, not to mention the actual decision making!

In a fun but scientific twist I offer a solution–give a doctor a bag of candy and we’ll make better decisions!

Our mental attitude effects how we make decisions.  If we are in a negative frame of mind, we tend to close down to other diagnoses and solutions, focusing on the obvious.  Furthermore, we are less likely to think in depth and go beyond the problem in front of us.    We are also less likely to engage the patient.  A body of work has been published, examing how affect effects clinical problem solving.  If a physician has a positive frame of mind, he or she is more likely to perform a deeper analysis of the problem, be more organized in the thinking process, and arrive at a correct decision faster!

Surprisingly, a similar study showed that giving a physician  a bag of candy, categorized as a small act of kindness, placed the clinician in a more positive frame of mind and inproved decision making. So what to do if no one is handing out bags of chocolate? Simply thinking about a good friend, or a favorite pet was also enough to shift frame of mind toward positivity and better decision making.

It may seem silly, but give it a whirl. I’ll try it out this week and let you know.  In the meantime, of course, you are welcome to send chocolates my way.  I am particularly partial to chocolove chocolate bars–the dark chocolate with raspberries

PS: tomorrow I’ll update you on the mixed results of the “do one thing differently” experiement of last week.

I have been a Girl Scout leader for a long time, and this past weekend my troop went for a mountain bike ride.  (Hey, it’s Colorado–it’s what we do!) I am part of “Troop Xtreme” –a bunch of girls that have together since 1st grade that like to push life to the limits and do go deeds at the same time. Not a bad gig, really!

I was reflecting on why I am still a leader after 7 years, and realized that so much of what I do in life, and believe about life, can be summed up the Girl Scout laws.  Here’s the law, and following it, is how I try to live it.

“I will do my best to be
     honest and fair,
     friendly and helpful,
     considerate and caring,
     courageous and strong, and
     responsible for what I say and do,
and to
     respect myself and others,
     respect authority,
     use resources wisely,
     make the world a better place, and
     be a sister to every Girl Scout.”

Honest and Fair: just this past week, a patient asked me not to tell his wife his diagnosis.  I was torn, but, I told the patient that I couldn’t lie–I had to tell the truth, and if she asked me, I would tell her the truth.

Friendly and Helpful/Considerate and Caring: isn’t that why we all became doctors?

Courageous and Strong: I think we are required to be strong, especially in the face of crises.  No one wants a shrinking violet running a code!

Responsible for what I say and do: I have to say that one of my most basic core values of all is responsibility.  I don’t think we can be physicians unless we are willing and able to shoulder responsibility for not just the small things, but major ones–like some one’s life.  Sometimes, I have to admit, the weight of patient care seems overwhelming, however.

Respect for myself and others: as a physician, this has been my greatest area of growth over the last 5 years.  Now that I am more comfortable in my own skin, I can see other’s view points, and finally recognize that my way is not the only way.  This learning process especially is relevant when I have  different view points than patients.  I remind myself that what they believe is as equally relevant and important as my beliefs.

Use resources wisely:I’m better at recycling because of this law, but we all could use our medical resources more wisely!  I think this is the reason health care reform is so important–we are not using our health care resources wisely–for many reasons.  (E.g.: malpractice, tort reform, the public’s unrealistic expectations, etc…)

Make the world a better place: time will tell if I’ve left a mark.  I have to say that sometimes, it doesn’t feel that way.  I thought, back when I was 5 and thought I would save the world as a physician, that it would be much easier! I hope I am giving back.

A sister to every Girl Scout: this is one of the best things about being a Girl Scout–everywhere I go I meet leaders and former Girl Scouts.  It’s a great sorority to belong to! 

I’d love to hear about how Girl or Boy Scouting shaped your life–I’m a big believer in it!!!

As you know, I have been been working a lot of extra shifts since Hubby got his pink slip.  I knew I was burning out in mid September after taking about 5 extra shifts per month.  Here are my warning signs, and my anti-burn out plan. 

• Dread of going in to work that would start on my days off.
• Shortness with nurses on the phone.
• Excess whining at work on my part.
• My daughter asking, “do you really have to go to work today?  I haven’t seen you in FOREVER.”
• Over reliance on coffee.
• Hoping that someone else would get to the “Code Blue” first so I wouldn’t have to run it.
• Looking longingly at patients’ beds, wishing I could just sleep.
• Wishing I would catch H1N1 so I could stay home, but no, my iron clad immune system is too strong!
• Yelling at hubby to “get a job, dammit!”
• Regretting instantly how b—-y I have been to just about every one in my life.

Anti burn out plan:

• Over the top self care.  I got two 20 minute neck massages at WholeFoods before I went in to work.
• Reducing the amount of shifts I am willing to work.  I cut down by a couple each month, starting in December.  (That’s the soonest I could change my schedule.)
• Bring in good lunches/dinners to work.  No more high fat, high calorie doctor’s lounge junk!
• Getting out side.  It’s beautiful out here in Colorado.  Getting out for a walk with my hyper dog (a vizsla, if anyone wants to know) helps her and me!
• Saving the notes my daughter puts in to my lunch box.
• Reminding myself that this too, shall pass, although it sure feels like a kidney stone right now!

And what do you do to avoid flame out?

PS: there is a nice summary of an article from JAMA on reducing physician burnout over at KevinMD.

The utility of an EMR lies in it’s utility.  Today, I heard about yet another practice that had paid for an EMR, installed it, and yes, you guessed it, had never used it!  Even more horrifying was the fact that this is the THIRD case of this I have heard in the last year!!! So what went wrong with the groups that purchased these unused EMRS?

They were deemed too complicated for use by the endusers- the physicians.

So what is the moral of this story? Due dilligence! And just to be sure sure, here is a short (and probably incomplete!) check list of buyer beware items:

• Make sure your office can affrord a good EMR. There is no cash for clunkers for EMRs!  Take in to account the initial purchase of the software, the hard ware required, the cost of IT upkeep and maintenance, as well as training.
• Involve the physicians in the decision making process.  Physicians, don’t you DARE sign off on something that you haven’t completely, thorough, painstakingly reviewed and researched!
• Make sure your office can afford the time it takes to train the personnel involved. Realize that office flow WILL slow down dramatically, and time per patient will go up.  Most EMRs, no matter how good, have a stiff learning curve.  Plan accordingly.
• Make sure your users are aware and accept that things will be slower and infinitely frustrating.  Don’t believe the reps when they say things like “office ready” or “easy” or “turnkey.”  Be realistic.  It will be painful.
• Have a super user.  Have one staff member, preferably a physician, learn the system way before it goes live.  That “super user” can then help the other physicians with their head aches, belly aches and gripes.  Physicians seem to handle input better when it comes from a colleague, rather than a medical assistant who now appears much smarter than the physician.
• Have enough computers to work off of.  Not enough workstations=no implementation.
• Failure  is not an option.  Commit to using the EMR from the get go, and don’t let anyone weasel out.  If your practice is making this step, it’s like a Catholic marriage: divorce is not acceptable.

So, commit!  Life in medicine is hard enough without an expensive, useless purchase.

What if physicians were reimbursed for talking about end of life decisions with patients? What if there was a code, say 99000-000.00 for the office based or bed side based talk with families and patients about end of life care? What if we could bill for one of the most important conversations we could ever have with patients?

Health care costs would fall and patient satisfaction would go up.  We could bring the patient and family to the office, have copies of medical power of attorney and “living will” paperwork available.  We could talk about where the patient is with their disease and life. We could take the time necessary to make plans to do what the patient wanted when the end of life neared, and stop doing the testing and treating that some patients (read many!) don’t want at the end of life.  Instead we could focus on what patients do want: dignity, friends and family, and freedom from pain.

So, maybe, there should be a place for the “99000-000.00″ visit in this climate of health care reform.  Think of the benefits for all, most importantly, the patient.

PS: in the meantime, consider handing out a copy of this article from MSN Money to patients.  Maybe it will convince them to move forward on their own to get an advanced directive.

Because I love you, I have gone to the ends of the internet to find definitions of weird EMR terms. I found this at a website, edited it, and hope you will book mark it for future reference!  Check out the definitions of  ‘Snomed’ and ‘Thin Client’.  Like it or not, EMRS are coming your way!

ADSL:  A type of DSL that uses copper telephone lines to transmit data faster than a traditional modem. ADSL only works within short distances because it uses high frequencies with short signals.
ASP:(Applications Service Provider) A business that provides computer based services to customers over a network. Also know as SaaS (Software as a Service)
ASP:(Active Server Page) A dynamically generated web page with ActiveX scripting, which executes on the server instead of on the Web browser (HTML). The Server executes the file and generates an HTML formatted page for Search Engine Spiders or Web Browsers for proper display.
BMI charts: Charts within EMR systems, which can manipulate data, perform calculations, and adapt to user preferences and patient characteristics; users may expect greater functionality from electronic BMI charts

CCHIT: Certification Commission for Healthcare Information Technology, the recognized certification authority for electronic health records and their networks, and an independent, voluntary, private-sector initiative.

Citrix Server: A server solution, similar to Microsoft Terminal Services that provides remote access to clients via the web or to dummy terminals in a network.
Clearinghouse: A company that provides clearing and settlement services for medical financial transactions. Some of the more popular clearinghouses include Emdeon/WebMD, McKesson and THIN.
Client-Server: A network architecture which separates the client (often an application that uses a graphical user interface) from the server.
Computerized Patient Record (CPR):  Also known as an EMR or EHR;.a patient’s past, present, and future clinical data stored on a server.
Computerized Physician Order Entry (CPOE): A system used by physicians to electronically order lab tests, imaging and prescriptions
Continuity of Care Record (CCR): A new XML standard being developed for EMR software vendors to follow which will theoretically allow patient data to be easily moved from one EMR vendor to the next in a structured database format.
Digital Imaging and Communications in Medicine (DICOM): A standard to define the connectivity and communication between medical imaging devices.
Drug Formulary Database:Used for electronic prescribing, electronic medical record (EMR), and computerized physician order entry (CPOE) systems to present formulary status to the provider while during the prescribing decision.
EDI: Electronic Data Interchange. Electronic communication between two parties, generally for the filing of electronic claims to payers.
Electronic Medical Records (EMR):  Electronic Medical Records. A computerized record of a patient’s clinical, demographic and administrative data. Also known as a computer-based patient record (CPR) or electronic health record (EHR).
Electronic Eligibility: An EMR feature which gives a payer access to deliver up-to-date insurance benefits eligibility information on patients.
Electronic Health Records (EHR): See Electronic Medical Records (EMR)

First Data Bank: The leading provider of drug information. Provides context and integration information for heathcare of every type at every level.

HCFA (CMS-1500 Form):The insurance claim form that a healthcare provider turns in to an insurance company.

HL 7 (Health Level 7):Part of the American National Standards Institutes accredited Standard Developing Organization (SDO);the Health Level 7 domain is the standard for electronic interchange of clinical, financial and administrative info among healthcare oriented computer systems. A not-for-profit volunteer organization, it develops specifications, the most widely used of which is the messaging standard that enables disparate health care applications to exchange key sets of clinical and administrative data. HL7 promotes the use of standards within and among healthcare organizations to increase the effectiveness and efficiency of healthcare delivery. HL7s international community of healthcare subject matter experts and information scientists are dedicated to the creation of a standard architecture for the exchange and transmission of clinical data.
Hybrid Record:  Describes a provider using a combination of paper and electronic medical records during the transition phase to EMR.

IEEE:  the Institute of Electrical and Electronics Engineers.

Legacy System:Term used to describe an outdated system (usually hardware and software), ie. old medical billing software system.
MEDCIN:  Clinical documentation nomenclature designed to provide E&M level coding assistance to providers through the use of a extensive database for documenting patient encounters.
Multum:  A popular drug formulary and alerts database.
Picture Archive Communication System (PACS): Used by radiology and diagnostic imaging organizations to electronically manage information and images.
Patient Portal:  A secure web-based system that allows a patient to register for an appointment, schedule appointments, request prescription refills, send and receive secure patient-physician messages, view lab results, pay bills, and access physician directories.
RAID (Redundant Array of Independent Disks):  A way of storing the same data in different places on multiple hard disks. Often used on servers to provide redundancy in the event of a hard drive failure.
SNOMED:  (SNOMED CT) Systemized Nomenclature of Medicine Clinical Terms. The medical language standard which details health care terminology, providing comprehensive coverage for procedures, diseases, and clinical data. SNOMED CT helps to structure and computerize the medical record while allowing for a consistent means of indexing, storing, retrieving and aggregating clinical data across sites of care (i.e. hospitals, doctors offices) and specialties. Snomed CT, in standardizing clinical vocabularly reduces the disparity resulting from the way data is captured, encoded and used for clinical care of patients and research. It allows for more accurate reporting of data and is currently available in English, Spanish and German.
SQL:  Structured Query Language: A computer language aimed to store, manipulate and retrieve data stored in relational databases.
Stark Law:  Part of the Omnibus Budget Reconciliation Act or 1989 the Stark Law prevents hospitals from purchasing EMR software and other equipment for private practice physicians in an effort to atract referrals.
SureScripts:  Electronic exchange that links pharmacies and healthcare providers. Founded in 2001 by NACDS to make the prescribing process safer and more efficient.
T1, T3 line:A high-speed internet connection provided via telephone lines often used by businesses needing internet connection speeds greater than DSL/Cable.
Terminal Services: Microsoft’s method for remote administration tasks that delivers the Windows desktop and Windows-based applications to nearly any personal computing device, even devices that can’t run Windows.
Thin Client:  Also known as a Dummy Terminal; a network computer without a hard-drive which requires a constant connection to a server for operation.
UB-92 Form:Form designed for hospitals to file a medical claim with the patient’s insurance carrier.
UNIX: A network capable, multi-user operating system used for workstations and servers. Many old practice management, medical billing and EMR software were originally designed under the UNIX operating system.

Web-based EMR: See ASP (Application Service Provider)
XML (Extensible Markup Language):  Used for defining data elements on a Web page and communication between two business systems. Example: Standard messaging system for and EMR to integrate with other software such as a practice management or drug formulary database.

Readers who follow this blog probably know that my husband is a pilot, and that we fly around in his small plane.  He avidly follows up on plane crashes, near misses and other hazards of general aviation.  Along the way I have learned a lot about aviation that can be applied to medicine.  Hubby tore out an article from the June AOPA (Aircraft Owners and Pilots Association) magazine and insisted I read it.  It was titled, “The Aviation Safety Reporting Program.”

His point: physicians need an agency to which we can report “near misses.”  General Aviation has the Aviation Safety Reporting Program, which allows pilots to anonymously report flying “incidents.”  The pilot is then granted immunity from loss of pilot’s certificate provided the violation was inadvertent, not deliberate, and didn’t result in an accident.  The FAA investigates the incidents and looks for systems problems. After analysis, the FAA issues ‘alerts’ and guidelines in attempt to correct the problem.

Heath care would benefit. If physicians could report freely, with out penalty, the mishaps that occur through the day, and report them in a standardized fashion, much progress could be made.  Systems errors could be analyzed and corrected.  This would require lots of reporting to make a robust data base, but having an unbiased investigator and the “no penalty” aspect would encourage reporting.  From that data base much would be gleaned about recognizing and preventing mistakes that occur from systems errors.

We have learned a lot from aviation–read backs and checklists are great examples.  We should also learn how to meticulously analyze our own near misses and crashes so they don’t happen again.  We need an entity similar to the Aviation Safety Reporting Program.  Perhaps the “Medical Safety Reporting Program?”

For interest, check out the safety blog, which details  JFK Junior’s fatal crash in to the waters of Cape Cod.