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

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!

Part of what makes medicine so difficult is the constant time constraints we are under (or perceive we are under.)  I have grappled with ways and styles of communicating effectively, and some days are better than others.  I found a monograph entitled “The Four Habits Approach to Effective Clinical Communication” by Richard M. Frankel, PhD, et al to be helpful. 

Following is an excerpt on delivering bad news.  I find giving bad news particularly challenging, as frequently, there is nothing to say or do that makes it any better.  Hopefully following the steps below will allow physicians to do it with greater grace. 

• Prepare for the visit by having an appropriate time and place  (not the hall way of the hospital!)
• Have a plan for what you wish to accomplish.
• Get the patient’s perspective before giving your own.
• Use clear, unambiguous language, and be brief.
• Be silent after you have delivered the news to allow the patient to process the information.
• Limit the goals of the visit once the news has been delivered. (In my experience, once you say the word “cancer”, patients become unable to process further information.)
• Check for patient and family understanding.
• Plan the next steps for short, medium and long term goals.  (E.g. “tomorrow, you will see brilliant Dr. Oncologist, and then next week likely start chemotherapy.  Long term, you should recover fully.”)

Good luck out there.  Let me know if you have ways you deliver bad news to patients that seem to ease the pain.  Isn’t that why we are physicians?

If your practice uses a medical practice manager, you sure as heck need to know what they do, and have a system to evaluate your manager.  If you are running the practice yourself, you should grade yourself against the following standards:

Who is watching the shop?  The manger should have bench marks for collection ratios, employee use/overtime, submission of claims, copay collection, and financial reports.  The manager needs to submit reports and communicate with you in a regular, coherent fashion. Your job is to understand what the manager is telling you and know how to make decisions based on the bench marks just described.

Roll with the Punches.  The manager should develop strategies to adapt to changes in payor policies, changes in regulations and how to comply with these changes– (think HIPAA, CLIA, ICD-10, EMRS).  You want a nimble practice manager who can guide you through these changes with the minimum of fussing and maximum efficiency. Your mission: understand how your practice will change, and have a plan to implement these mandatory changes.

Be a mirror.  The manager should reflect your philosophy on patient care,  treatment of employees, motivation of employees and general mission of the practice. Your to do list: make sure YOU know and communicate your vision for your practice.  Practice managers aren’t mind readers.

Please, do not bury your head in the sand and assume that your practice manager is doing a swell job.  Start reading those reports they SHOULD be giving you, understand what the implications of these reports are, and start creating the practice you want to be in.  Hoping that everything is okay is not a strategy, it’s just wishful thinking.  Sorry, charlie, but you gotta be more than a physician, you have to be a business person too.

Photo credit.

I have been roaming the ends of the earth (or the Internet!) to find ways that primary care physicians can utilize the web WITH OUT an expensive EMR.  (As Jonathan Oberlander, a political scientist from  of UNC-Chapel Hill, commented with respect to EMRS, “We are not going to be able to compute our way out of that (health care) mess.”)  Following are ways to use your practice’s website to better manage your practice.

Here are 10 ways you and your patients can use your website to increase efficiency.  (Please see previous post on “mouse calls.”  Don’t give away services that you should be reimbursed for!)

1. Make appointments.  A website is a great way for patients to make appointments.
2. Send statements and have credit card billing available.  Use your website to sign up for this.
3. Request refills.
4. Complete preregistration, either via secure online portal, or via a PDF that patients download.
5. Ask questions to nurse or doctors.  (Careful here–HIPAA considerations apply, and again, billing in this area goes case by case, insurance company by insurance company.)
6. Allow patient to create a personal health record.  (How useful these are remains to be seen.)
7. Request medical records.
8. Obtain results of tests. 
9. Blog.  Patients love blogs about topics like how to manage their weight, ways to avoid colds, why they should get a colonoscopy etc.
10. Link to health sites such as WebMD.

I think having a website is crucial to a modern practice, and is a great way to start to learn more about Web 2.0.