Archive for category Medical Records
The AMA has 7,800 codes for all types of medical services. Discussion of end-of-life care has been considered part of routine primary care. Now, the medical-industrial-complex wants another fee for the service of discussing this topic.
The service in question is “Advance Care Planning“. Certainly, a good idea — a health care provider should be talking with patients about end of life issues. We all die, that seems obvious, but someone should ask: “when it does happen where do you want to be, who would you like to be there, and have you told someone about your wishes for medical care at the end?”
Virtually anybody can ask those simple questions. Sure, getting up the nerve to ask the questions is hard for family members. And, sometimes there is no family to discuss the questions or the answers. Like other issues of health care, the primary care provider should broach the questions and record the answers and facilitate discussions with the people close to the patient. It’s not a question that needs repeating at every visit, but periodically as conditions change. Is the discussion important? Absolutely. Soap operas are not where the answers exist.
There is an undercurrent of distrust. The distrust is because the medical profession seems so motivated by profit they may do unnecessary treatments when death is near. Thus, to avoid unnecessary treatment a person must clearly state what medical services are wanted at the end of life.
The issue is clouded by the huge shift in the doctor-patient-relationship over the past 10 years. The doctor who might see the patient in the primary care outpatient clinic is not the one who will see the patient at the care center, or the oncology clinic or be the admitting physician at the hospital. Unless the patient, family and friends have a clear grasp on what the patient wants the information may be lost or be misrepresented. It would be incorrect to think the medical record will be universally available — it’s not now and will probably not be that way for decades (if ever).
An equally difficult problem is the “grey area” between care that works and futile care. “Is this the end?” The care provider who is asked that question is really on the front line, not the primary care provider who discussed the issue 10 years before.
The elephant in the room is the cost of care. And, the fact many people do not have the resources to pay tens of thousands of dollars a month for care when their income is just Social Security. Very few people say “do everything”. But, can a person with no resources actually say “do everything” and expect that to happen?
The bottom line: the new CPT codes pay for something a primary care provider should already be doing so the additional cost is not needed. If the discussion is not happening then it is a case of poor quality primary care. Paying more never makes low quality care better, it just makes poor quality care more expensive.
An end-of-life discussion with a knowledgeable provider tends to set expectations in a reasonable range. Satisfaction with medical care is often about meeting expectations, so this is important for the patient and the care providers. It also should set expectations for friends and family — after the patient dies they are the ones who decide if expectations are met.
The International Classification of Diseases version 10 is called ICD-10. Here is an example: S06.5X9A You can look this up on the CMS web site (ICD-10 Lookup) to find “Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter (that’s bleeding around the brain due to a blow to the head which the provider evaluated for the first time).
So, why is this important to you as a health care consumer? Because the bills sent to insurance companies use these codes — if the code is wrong then insurance will reject the claim. By looking up the code you will actually know the technical diagnosis made by your provider — something to add to your DIY medical record especially if it is a critical diagnosis in your situation.
The diagnosis codes are intended to force providers to be very specific about the conditions they treat. The people who connect diagnosis to outcome find the codes very valuable — which in turn helps consumers know how providers perform.
The codes are not always seen by the consumer — they are transmitted on insurance claim forms. In fact, insurance companies will refuse to tell you what diagnosis was used to bill services. But, the codes often find their way into the medical record — as they should.
The ICD-10 code tells the diagnosis. A companion code called Current Procedural Terminology (CPT code) tells what service was provided (like an office visit, or perhaps a brain surgery). ICD codes are in the public domain but the CPT codes are produced by the American Medical Association and are copyrighted.
From a purely economic standpoint the CPT codes serve primarily to fractionate the health care market to maximize profit for providers. It is helpful to know what service is provided but the CPT codes are blighted by meaningless detail. And, they are hard for the consumer to decode because of the proprietary nature of the codes. Many feel the CPT codes are part of the cause of high health care cost in the US. They should be scrapped and replaced with some international standard.
Snowbirds: watch out for high medical costs in Florida, Texas, Arizona and California. According to Elisabeth Rosenthal in the New York Times 2/1/15 “Patients Find Winter Havens Push Costs Up”. She points out providers in Florida are the worst offenders — the same place notorious for Medicare fraud!
Ms. Rosenthal highlights one patient from New York wintering in Florida who had a checkup for his pacemaker but did not have any new symptoms. Many in-office tests were ordered by the substitute cardiologist — tests the patient’s regular cardiologist said were unnecessary.
To be very blunt: cardiologists, and other providers, who order in-office tests make a lot of money from those tests. Many studies show providers who profit from tests do more tests than providers who don’t profit from tests. A medical license is not a license to take advantage of patients or Medicare — profit motivation seems to blind some providers to this distinction.
The lure of profit is made greater by a patient not having any new symptoms, not having any record of previous tests, and not having plans for follow-up visits. It is like the patient has a sticker pinned on their back: “TEST ME”. The choice for the cardiologist is simple: either pay the nurse to spend time getting out-of-town records OR make money by repeating tests. Make money, right!
- If you are on vacation and have a sudden health problem your best bet is an urgent care center. They can send you to a specialist, if needed.
- If you have health problems and will be spending several weeks or months away from home:
- Talk to you primary care provider: they may want you to call in and give a report on the phone (diabetes is a good example). If so, no office visit may be needed while away.
- Get enough medication to last the trip. Or, get prescriptions with refills at WalMart or Target and have the prescription transferred to a store near your winter location.
- Identify a doctor to see in your vacation area before you leave. Ask friends or other people who winter in the area for a recommendation. Call the distant provider office and get a FAX number so records can be sent.
- If your primary care provider thinks you need a health care visit while you are away then make an appointment and have your records sent before you leave home — also take a paper copy!
- If tests or surgery are recommended then call your regular doctor’s office to see if they agree.
- Give any provider you see your regular provider’s name, address, phone number and FAX number (a business card is good). Request that results of visits, tests or hospitalizations be faxed or sent to them — and make sure it happens. Fill out a release of information form while you are at the office or other facility.
Doctors have long complained they don’t get paid to solve problems over the phone. Now primary care providers (not specialists) can charge $40 per month for something called “Chronic Care Management.” (CCM)
If you have several long term and serious conditions like diabetes, congestive heart failure and chronic obstructive pulmonary disease then Medicare will pay $32 per month and you or your supplemental insurance will pay the rest for this service. Many supplemental insurance plans have deductibles and co-payments — so many, if not most patients will be paying an extra $8 per month.
Who actually does all the work? The office nurse. The doctor supervises the decision making.
You will have to sign a consent for CCM in order for the doctor to bill you each month, so it is important to know what to expect. Some doctor’s offices will make the service helpful but in other offices you may never know where the money is going.
If you can’t tell you are getting CCM then simply stop the service — revoke the consent with a letter “Dear Doctor, effective at the end of this month please stop “Chronic Care Management”. I will continue visits as usual.”
In general, CCM is a good thing. Here are some of the problems it solves: Without CCM many doctors just don’t take the time to coordinate services except as part of an office visit — if you go to the emergency room the primary care provider would not act on recommendations until you actually go for an office visit. If your visiting nurse suggests some course of action then you go for an office visit. If you want to see a specialist you first go for an office visit. If you get discharged from the hospital and need physical therapy you go for an office visit before it will be ordered. With CCM the doctor gets $40 per month to coordinate care without always going for a face-to-face visit.
The minimum requirement for the provider is to spend at least 20 minutes per month working on your case without seeing you in person. Here is a list of things providers of CCM are required to do (at no extra charge) and thus things you should expect:
- Transitional care management: meaning admission or discharge from some medical service or facility (like giving orders for physical therapy after hospital discharge or providing full medical records to a rehab facility)
- Supervision of home healthcare. The provider gives orders for home care with lists of medications, duration of treatment and goals of treatment.
- Hospice care supervision.
- Provide a limited number of end-stage renal disease services.
The provider must have 5 capabilities and use those capabilities as needed:
- Keep your records in a computer
- Create a care-plan — an outline of goals and actions the provider will follow to meet those goals. Like “keep blood sugars in control — by weekly phone contact”. The provider should give you a copy of the plan — it should be specific to you and not a standard form applicable to anyone.
- Provide phone access to talk to a someone associated with the office 24 hours per day (they should be able to look at your computer record). Provide office visits as needed (presumably same day for urgent problems and within a week for non-urgent problems)
- Facilitate transitions in care. Like provide prescriptions and orders for therapy after discharge from a hospital or providing medical information to specialists for each visit. Or, keeping orders for home oxygen up to date. Or, immediately sending outpatient medical records to the hospital where you are admitted.
- Coordinate care. This does not mean providing all care, it is not a wall around you. If you need to see a specialist the provider makes sure all your medical data is transmitted to that specialist and makes appointments for you. And, follows the instructions of the specialist (as medically reasonable). Engages therapy such as home visits by nurses, physical therapy, occupational therapy or social service. And, makes efforts to meet the care needs outlined by those therapy services (as medically reasonable).
CCM does not eliminate office visits but it makes sure loose ends are dealt with and it obligates the provider charging CCM fees to provide access to someone that can look at your chart 24 hours per day. It also means the ER can call the primary care provider office and get up-to-date medical information about you in an urgent situation.
Disclaimer: the rules and fees for this program are in a state of flux. What is true today may not be accurate tomorrow. So, discuss the meaning of CCM with your primary care provider. Give them a copy of this article as a place to start a discussion. Here are some additional helpful links:
What are the causes of hospital readmission? A previous post details the most significant factor: fragmentation of health care. This post focuses on disease and the condition of the patient at discharge.
Until the past 5 years the prevailing view of re-hospitalization was it is unavoidable due to the nature of the chronic disease. The view changed when studies showed strong outpatient social and medical management vastly reduce re-admissions.
And yet, disease does catch up with those afflicted causing eventual death. Sometimes patients are discharged from a hospital and much to the surprise of clinicians the patient is back in the hospital before outpatient care can engage to deal with a potentially unstable situation. Even before the outpatient check 4 weeks after discharge the person decompensates and is hospitalized again.
Frustration born out of rapid re-hospitalization lead Michael Rothman to develop a statistical method to alert clinicians before hospital discharge to the presence of high risk. Whether the outpatient care network is sufficiently robust to act on the information is possibly the bigger issue. But, consideration of the “Rothman Index” is worth a few comments.
Mr. Rothman published the statistical findings “Development and validation of a continuous measure of patient condition using the Electronic Medical Record” (Journal of Biomedical Informatics 46 (2013) 837–848).
Rothman found he could predict bad outcome (and hospital re-admission) based on routine measurements done in every hospital, just combined in a statistical way. He divided the measurements into 3 equally weighted groups of (1) lab tests, (2) nursing observations and (3) vital signs. Overall there were 26 items such as potassium level, nursing charting by exception (like normal or abnormal respiration), and blood pressure. The index started at 100 and if all items were normal the index stayed at 100. But, if items were abnormal an amount was subtracted. The lower the score the worse the situation. In fact, he showed his index correlated with the 1-year mortality of the patient. The lower the index at discharge the more likely was re-hospitalization and even death. Mr Rothman started a company to calculate the index for interested hospitals.
The idea is great: identify high risk patients and focus more outpatient resources quickly.
Doctors always try to normalize abnormal findings. If the heart rate is too high find out why and correct it. If the potassium is too low find out why and correct it. If the blood pressure is too low find out why and correct it. When the end of the hospitalization comes hopefully everything is in the normal range. The Rothman Index basically says that if a concerted effort by doctors fails to normalize findings it means the patient will do poorly (an abnormality caused by a stroke just can’t be normalized). The very definition of chronic illness is that it can not be resolved by modern medicine.
Rothman’s research shows some interesting findings. The 1-year predicted mortality is increased by 10% if any the following findings are present at discharge:
|Clinical item||absent or below||present or above|
|Blood Urea Nitrogen||–||25|
|White Blood Count||4,000||14.000|
|Heart Rhythm|| anything other than
|Braden Scale (link)||19|
| Nursing Assessment
| any body system
The Rothman Index is important and either that index or other similar index should be calculated at discharge. If the index indicates an increase in mortality then questions need to be asked and answered:
- Have the abnormal findings been investigated and treatment started — if an available treatment has not been started it should be.
- Has enough time passed for the abnormal finding to normalize — if not the patient should either stay in the hospital or be seen as an outpatient in just a few days.
- The estimate of a poor prognosis should be discussed with the patient and family to make sure they understand why follow up is important.
- If the estimate of poor prognosis is very high (over 50% 1-year mortality) and not expected to improve then planning for death should be started.
Your medical history is very important because health care providers use that information as the foundation for medical decisions. Who has more interest in the accuracy of your information than you do?
You might say: writing the medical history is the doctor’s job. You are right. But, have you actually looked at the product of that work? — most people have not. Patients who read the doctor’s version of a medical history are astounded by the number of errors and the amount of missing information. To be fair, health care providers are goal oriented — as they hear the medical history they make diagnoses and once a diagnosis is made the details become less important.
Health care providers absolutely love a new patient that hands them a concise medical history. They love it because:
- They save time
- The information is more accurate and complete than usual
- They can take notes directly on the paper
- It is an aid to write their own version or enter data into a computer
The do-it-yourself (DIY) medical history is great for patients because:
- You don’t need to repeat it on forms, just write “see attached Medical History”
- You can print a copy when you see a new doctor or specialist
- You can take a copy to the emergency room
- You can keep it up to date with a wordprocessor
- You can store it on your computer or “in the cloud”
- Your health care visits can focus on current problems not old records
As helpful as this DIY medical record seems there are some important points:
- The record must be constructed the way health care providers expect — otherwise they will not read it or use it.
- The record must be concise — try to get it on one page (not more than 2 pages)
- You must not omit diagnoses or include any self-made diagnosis
- Avoid duplication — if you include something in one section do not put the same information in another section.
- This is not a test. You can “cheat” by copying from the medical history created by one of your health care providers. After all, it’s your medical history. Make sure you get copies of any “History and Physical” done by your providers.
When you see a new health care provider you should take 2 things:
- A copy of your DIY medical history.
- A small piece of paper with the 3 concerns you want to talk to the provider about
Now, to the nuts and bolts of the DIY medical history. Here are the categories:
- Identifying information: Name, Date of Birth, Address, Phone number
- Past Medical History:
- various diagnoses with dates of any hospitalizations and causes
- recent blood tests, x-rays or other tests with results (or attach report)
- Past Surgical History: name of surgeries with date, surgeon, and hospital
- Childhood illnesses: birth defects or serious illnesses when a child
- Obstetrical History (women): pregnancies and outcome, number of children
- Psychiatric History: depression problems etc. and list of hospitalizations
- Family Medical History: just parents, siblings and children
- Social History:
- where you live, with whom, occupation, when retired etc.
- habits including smoking and alcohol consumption
- advance directives (living will, 5 wishes etc.)
- drug names, strength, how often taken, for what
- pharmacies with phone and fax numbers
- Drug Allergies
- Drug Intolerances or side-effects, what drug and when it happened
- Food or Inhalant allergies
- Immunizations: which vaccines and when
- List of current health care providers: primary care, pediatrician, ob/gyn, and specialists
- Prefered hospital in case hospitalization needed
- Emergency contacts: names, relationship and phone numbers