The Art of Medicine: Evidence-Based vs. Evidence-Enhanced

Medical care has evolved from using the individual practitioner’s training belief system, and own personal bias to using data, studies, and evidence to make appropriate decisions. This more scientific approach has yielded better results and more rational treatment programs.

However, in the mantra of “double-blind-controlled study," there is another side of medicine that needs to be addressed. This is the “Art of Medicine”.

Medical care not only includes scientific assessments and treatment protocols but also the human side. Patients come for the best scientific care but also for compassion, empathy, measured opinions, and guidance.

The Electronic Health Record (EHR) gives access to the data, but not the whole story.

By combining “evidence-based medicine” and the “art of medicine” you will achieve “evidence-enhanced medicine” giving the patient a holistic approach for which they are grateful. There is a reason other than scientific medical care that patients are nostalgic for their “own doctor."

Why Your EHR is "Creepy"

The definition of creep according to Wikipedia is the tendency of a solid material to slowly move or deform permanently under the influence of stresses.

           

The software you are dealing with is in a constant state of flux leading to multiple changes that may inadvertently lead to user dissatisfaction.

1.      Version “creep”—constant upgrading of the software with leads to potentially unwanted changes.

2.      “Creeping Elegance” ---- developers seeking the “HOLY GRAIL” of perfect software while detracting from its fundamental utility.

3.      Government “Creep”------ new rules every month that forces the software to make changes that may or may not be in the actual user’s interest.

4.      Payment “Creep”---“meaningful use” is a classic example of making programmatic changes to reimburse the client for their investment. Whether the purchaser recoups their investment remains to be seen.

5.      “Enterprise Creep”---- the institutions purchases an enterprise computer system (full hospital system) not designed for the particular end-user ( i.e. –no specific ED module). This may force a relatively satisfied user to reinvent the wheel.

The goal is to find an end-user friendly product that helps the provider rather than putting up a spider web of obstacles.

2 Hour Length of Stay in the ED - Would You Like Some Fries with That?

In the ED community there is a new marketing tool—30 minute or less no-wait ED service.

The implication is a provider (physician, PA, or NP) will greet you- a la the Wal-Mart greeter- to begin the service relationship. There are billboards, internet advertising, etc. that proclaim your care will be improved because it will be faster.

If properly conducted where the patient is fully evaluated, there should be significant PRC or Press-Ganey score improvements.

I would prefer to see the metrics based on speed, quality, and outcome.

This would be the “ED Value Plan” that encompasses speed, efficiency, communication, and quality. (9 out of 10 members in my family would choose this plan).

The provider will discharge, admit, or carefully discuss with the patient and family the “Battle Plan” for disposition at the 2 hour mark.
1. Discharge prior than 2 hours
2. Admit prior than 2 hours
3. Discussion with patient.
         a. Outline the timeframe
         b. Discuss need for more tests (CT abdomen)
         c. Waiting for consultant
         d. Providing more treatment to avoid admission (i.e. fluids, 2nd set of              troponin levels

Guest Blogger - Jim Tate: EHR Incentives Drop Dead Dates

Several times a week I am asked the same question by providers and vendors. The question takes different twists and turns, but it all gets down to one core concern. To put it in the crassest terms, here it is. “What is the absolutely last drop dead date an eligible professional can meet the CMS EHR Incentive Program requirements and not leave any money on the table?” OK, now that the question is clear, let’s answer it once and for all.

For Eligible Professionals there are two CMS programs, Medicare and Medicaid, which incentivize EHR use. An EP must select one of the programs for participation, and is allowed to switch programs once. Let’s take a look at Medicaid first. 2016 is the “Last year to initiate participation in the Medicaid EHR Incentive Program” and 2021 is the “Last year to receive Medicaid EHR Incentive Payment.”

To continue reading this blog visit: http://www.hitechanswers.net/ehr-incentives-drop-dead-dates/

Jim Tate is a nationally recognized expert on the CMS EHR Incentive Program, certified technology and meaningful use and a partner in HITECH Answers. He is also author of The Incentive Roadmap® The Meaningful Use of Certified Technology: Stage 1.

HITECH Answers - www.hitechanswers.net

To purchase Jim Tate's book "The Incentive Roadmap The Meaningful use of Certified Technology: Stage 1 visit:  http://www.hitechanswers.net/products-page/

Medication Reconciliation and E-Prescribing

E-prescribing is a certification requirement for out-patient clinics and urgent care facilities for EHRs to obtain "meaningful use" monies from the government. E-prescribing is desirable for patients, but its real objective is medication reconciliation.

This process is intended to be convenient for the patient; however, there is also an underlying goal to achieve medication reconciliation. The goal of medication reconciliation is important, but it is also time-consuming and labor intensive.

The problems associated with e-prescribing are:

• Who is going the input the info?
• Who is going to keep it updated?
• What is the time frame?
• Accuracy depends on patient and data collection

E-prescribing can only be accomplished if medication reconciliation is performed by the E-prescriber and his/her software. This puts the burden on provider and his/her staff.

Liability and the Electronic Health Record

The electronic health record (EHR) should lead to patient safety and help minimize liability, but there are built in-traps that come with it. These traps can be subtle and can lead to quality reviews and potential liability for the provider.

Potential Traps:

1.      Timestamps—all over the place. These can be recorded but may not necessarily reflect true clinical activities. Not paying attention to document when things really happened.

a.      EKG was signed off 1 hour after the patient was already in the cath lab

b.      Clinical course out of sequence with CPOE and nursing notes

c.       When a consultant was called  and their advice

2.      “cut and paste”---“cut and paste”  Copying and pasting information can be as harmful as it is helpful. Information can easily be repeated or copied into the wrong section.

3.      “Cookie-cutter” charts that are  loaded with data that may or 

      may not have occurred.

4.      Inability to easily access nursing notes- and the converse. The world famous “DR aware” note.

5.      Not knowing the status of treatments orders, even though the computer says they are signed off.

6.      Clerical errors on the CPOE.

7.      Not creating a work-flow that emphasizes timed data points that affects LOS/time to provider/time to decisions. If the providers are not “clicking” the tracking board, the     data suggests inefficiencies. Hospital management only looks at the data and rarely any excuses.

8.      Timelines are much easier for the plaintiff's attorney to create, which may look jumbled even though the reality was different.

9.      Not checking the output on key areas to make sure it reflects what was supposed to be communicated.

10.  Receiving a transfer patient with “40” pages of computerized documentation and missing the key.

Dictation Software - The Best Way to Avoid Traps:

In the clinical course, use dictation software or voice-activated technology to create a recap of all the events. I prefer to use Dragon Medical dictation software. A quick summary will indicate the battle plan, the response, and the disposition.

Paper, dictated, and electronic charts are all good for the initial evaluation and the disposition, but the clinical course is usually murky and left up to the imagination.

Does Medicare Reimburse for “Pharmectomies?"

Living in Florida, we see large number of elderly, chronically-ill patients with multiple medical problems.

These patients have multiple providers – primary provider, ED provider, nursing home provider, hospitalists, consultants, etc.

This leads to multiple treatments and prescriptions that have endless interactions and reactions.

After the medication reconciliation is completed on the Electronic Health Record (EHR), the process does not simplify.

So we have changed our process at my ED. Now if your medication bag weighs more the 5 lbs., we admit that patient to the hospital for a “Pharmectomy” - we eliminate all the medicines and start over. 


We are currently searching for a “surgical code” for this procedure as the reimbursement might be higher.