Posts Tagged doctors

Penalty for Failure to use EMR — CMS doing the right thing for patients

scoffing

Physicians scoff at rules requiring them to use electronic records and now they must pay the penalty.

Melinda Beck reported in the Wall Street Journal 12/18/14 “Medicare to Cut Payments to Some Doctors, Hospitals”.  Of the 893,851 physicians in the US, Ms. Beck reports 257,000 will be fined 1% of their Medicare fees for failure to adequately use an electronic medical record.

For example, the technically challenged doctors have failed to use electronic prescriptions, favoring instead marginally-legible  hand-written prescriptions.  And, they undoubtedly harmed patients by not taking advantage of allergy and interaction checks that are part of electronic prescribing.

AMA president-elect Steven J. Stack is reported as saying he was “appalled” by the government action.  Every physician, obviously excluding Mr. Stack, was informed 5 years ago that fines would be imposed in 2014 by Medicare if physicians that bill Medicare fail to use electronic records in a meaningful way.

Why would a rational physician choose not to use an electronic record…?

  • Because North Korea might hack the system
  • Because the government told them to use an EMR (they give orders, not take them)
  • Because they will be retiring soon and won’t need to learn about computers (the real reason)
  • Because they will need to pay for a system to help patients
  • Because young physicians want the systems, older physicians say no to all this newfangled stuff.
  • Because a an electronic record might be used in court against them.

There you have it — a detailed explanation.  Appalling, don’t you agree?

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Psychology of Unhappy Doctors — unmet expectations

ocdDoctors are unhappy because the medical world  is not what they expected (or dreamed about).

An essay in the Wall Street Journal today “Why Doctors Are Sick of Their Profession?” describes the feelings of many doctors.   What are those feelings?  What do they mean?

Most physicians cope very well and are quite successful in society.  Clearly, they do not have a psychiatric disorder as a group.  Yet, the WSJ article lists certain symptoms.  These are feelings of:

frustration, failed aspirations, malaise, worthless sacrifice, loss of control, conspiracy of lawmakers and insurance companies, devalued work, and recurrent intrusions of unpleasant thoughts.  Lawyers (the scum of the earth) make more money than they do.  And, oppression is keeping them from doing things the “right way”.

If a patient complains of those symptoms the diagnosis would be: depression with underlying obsessive-compulsive and narcissistic traits.  For doctors it may just be the world is not what they expected when they started 15 years of training.   The job is basically good and it’s too late to start over.

Is money an issue?   If a distraught patient says their anxiety has nothing to do with a “recent divorce” … it really has everything to do with the divorce.  If a doctor say it “has nothing to do with money” … it’s the money.

As a group doctors have a huge capacity for delayed gratification.  They go through difficult years of training by thinking it will get better later — the salary will go up, all the testing will stop, professors will go away, long hours will improve, and no one will question their decisions.  Welcome to the real world:  stagnant salaries, maintenance of certification tests, professors who set evidence based guidelines, long hours and insurance companies that question decisions.

Medical training is mostly to blame.  It’s too long, often unfocused, minimizes teamwork and shuns consistency.  The fight for doctors to follow evidence based guidelines is undermined by the constant drum beat of “cook book medicine”.  In fact, most medical treatment is by the book — a stunning revelation to most.  If physician expectations were better managed during training the dissatisfaction after training would not be an issue.

Many employees find their job the least stressful part of the day.  Stressed physicians need to focus on their job of diagnosis and treatment — it is very rewarding.  Extraneous worries can drive you crazy.

Accountable care organizations reduce physician stress by focusing physicians on the job of taking care of patients while business professionals manage the business.  Perhaps increasing the structure of medical care is the solution for physicians, not the enemy.

 

 

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Creeping Spread of Electronic Health Records

snailDelinquent, delayed and diverted the electronic health records in the US are missing.   According to the Washington Post two Presidents set 2014 as the target for all medical records to be electronic — so has American medicine hit the target?

According to a study by the Robert Woods Johnson Foundation US healthcare has been very slow to adopt the technology.  RWJF reports 50% of office practices have a “basic” system and 59% of hospitals have at least a “basic” system (25% of hospitals have a comprehensive system).  To give perspective, a “basic” system contains medical reports and medication lists but no physician notes.

Barriers stand in the way of progress:

  1. Medical data is a very valuable business asset.  EHR companies are threatened if such data could be easily transferred to a competitor.
  2. Fear of losing control.  Doctors and hospitals don’t want their data to be too available to insurance companies or regulators.  Quality problems could be easily exposed.
  3. Self-determination.  Health care entities want to make their own systems — the CEO would rather manage than cooperate.
  4. Lack of governmental action.  Doctors and hospitals are licensed by States — just putting the license at risk is all that is needed to make EHRs mandatory.
  5. High cost of building an EHR.  Every office practice and hospital needs a financial system.  But, really, only one EHR is needed in a State or perhaps only one in the entire US.  Hundreds of EHRs across the country is a waste of money — they all do the same thing, and they can’t “talk” to each other.
  6. Failure to embrace a “cloud” computing solution for a large scale EHR.

Ask your doctor:

  1. Please show me my chest x-ray on the computer screen in the office exam room.
  2. Please electronically send all my records to a specialist across town.
  3. Please show me a record of all the prescriptions I had filled this past year and which pharmacies filled them and how much they cost.  (surely you can trust your doctor with that small bit of financial information).
  4. Can I send you a secure email and expect a response?
  5. Can you securely send me the results of my tests?
  6. Can you easily look up the discharge instructions from my recent hospitalization on your office computer?
  7. Do all the doctors and hospitals and pharmacies in town share the same medical record system — why not?  It would be very good from a patient standpoint.

NO answers exemplify the current data problem.  The US has a far better tax system than a medical record system and a far better post office than a medical record system.  Contrary to the story in the Washington Post this is NOT OK.

 

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Rate Your Health Care Provider

The following rating system is intended for adult primary care office visits, but could also apply to some specialty visits.  There are no extra points for famous doctors, university clinics or the only provider in town.  Add up the points to see how your provider’s office is doing.

Performance Points
When I call the office, who answers?
 A real person 2
 A computer answering system that connects to a real person 1
I know the office will provide appointments:
New patient appointments within 3 weeks or
Follow-up appointment for new problem in 3 days
2
Urgent problem (during office hours) on same day 3
 The office designates time for walk-in visits  2
 The office has some evening and weekend hours  2
Moving through the office (assuming you were on time)
 Checked-in within 5 minutes 2
 Checked-in within 5 to 10 minutes 1
 Face to face with the provider
within 5 minutes of appointment time or
within 30 minutes for a walk-in visit
3
 Face to face with the provider
within 10 minutes of appointment time or
within 45 minutes for a walk-in visit
2
Checked-out within 5 minutes of leaving provider 2
Checked-out within 5 to 10 minutes of leaving provider 1
 Provider visit
 I do not have to take off clothes before seeing provider 2
 I can sit in a chair at eye level with the provider 2
 Provider seems to care about me 5
 I am not interrupted while I say the reasons for the visit 4
 The part of my body with problems is examined 3
 The paper chart or the computer is just used
by the provider to find information to help me
2
 The diagnosis of my problem is made clear 4
 I am directed to handouts or Internet sites about my problems 1
 Before I leave, the provider asks if I have any other questions 3
 It is clear when I need to return for recheck 3
 Medication Management:
 The reasons I need to take all medications are explained 3
 My provider sends prescriptions by computer 2
 Possible side effects of medications are discussed 1
 At each visit I receive a list of my active medications 3
 Tests (x-rays, blood tests, EKG, biopsies etc.)
If I need tests I am told why 2
 The office always lets me know test results within a week 2
 I always get copies of test results 2
 Practice environment
 My provider has associates who substitute when needed 2
 Hospital care is done by hospitalists 2
 My provider is part of a system including specialists 2
 Physician assistants or nurse practitioners work at the office 2

 TOTAL POINTS  =  

Score Rating
 60 and over  5 star
 50 to 59  4 star
 40 to 49  3 star
 30 to 39  2 star
 below 30  1 star

Hotels have struggled to get the coveted 5 star rating for decades.  It is not just whether the hotel chef can make a souffle but whether the whole experience of staying in the hotel is superior.   The items in the above score are considered elements of quality for health care delivery.  It’s not easy to get 5 stars.

Medical and surgical care has focused on diagnosis and treatment for hundreds of years.  To that end individual providers spend years, if not decades, honing diagnosis and treatment (some say, to a fault).   The vast majority of problems in primary care are fairly easy to diagnose (like diaper rash, acne and diabetes).  Treatment is harder because it spans time, is a process and requires patient engagement.  So, as it turns out, the wrapper may be as important as the package.  Providers are well trained and licensed but the wrapper of delivering care is where quality, safety, cost-effectiveness and satisfaction reside.

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