The Perils of Alert Fatigue

The authors of Alert Fatigue analyze and define the term as "...how busy workers become desensitized to safety alerts, and as a result ignore or fail to respond appropriately to such warnings."

They conclude:

1. Alerts are only modestly effective at best.
2. Alert fatigue is common.
3. Alert fatigue increases with growing exposure to alerts and heavier use of CPOE systems.

One of the potential great benefits of the electronic health record is clinical decision support, where artificial intelligence augments the baseline intelligence of the clinician.  The ultimate goal of CDS is to help the clinician 1- make accurate diagnoses', 2- use up to date treatment protocols, and 3- receive warnings about potential diagnostic and therapeutic pitfalls.

Troubles with intelligence (either artificial or natural) rise exponentially with the complexity of any issue.  For example, when one consults the PDR, every drug has hundreds of side effects and warning.  Ordinarily, the human brain filters these risks- many of which are hypothetical-and creates a mental hierarchy of potential dangers, on which action can be based.  However, when a computer performs the task of risk-retrieval, things become much more murky, since filters to prioritize, based on clinically relevant evidence, are pretty much absent, or if present, inapplicable.

Indeed most side effect warnings are inserted because pharma legal teams insert reference to every case report, not matter how obscure.  Otherwise- such non-medical counsels might argue- how could there be good defense against attribution of negligence, should a second atypical case pop up?  Putting such warnings into the adverse effect section of the ubiquitous PDR provides the possibility of escaping a lawsuit on the basis of physician or patient contributory negligence.  That is, the pharma defense team might argue, "they (the docs) did not (even) read the warnings!"

Attending to every one of the countless case-report engendered warnings would effectively take most medications- not to mention the clinicians- out of practical consideration.  On the other hand, some alerts are very serious and represent preventable errors that can potentially be avoided.  Balancing this voluminous input is hard on the human mind, and pretty much- without weighted prioritization- impossible for a machine.  Hence, the machine creates noise- repeated alerts- that the mind must deal with, and clinicians, getting inundated with endless warnings and signals, start ignoring them, even perhaps overriding their demands.

Human-factors come into play.  Protective desensitization to incoming stimuli is a necessary component of efficient cognitive activity.  Who among us has not become resistant to the noisy environment of an ED, just so we could get our baseline thinking in order?  The same can be said of a parent, working at home, with  chattering children running about.  Earplugs?  Well, sometimes.  But for the most part, many have learned to shut down the "noisy" input by "throwing an internal switch", one that no longer hears the kids screaming.  Repeated alerts, as we all have experienced, soon become just background noise.  Hopefully, thought, if the house is burning, the sound will be loud enough, different enough, for a red flag to arise.

This mirrors how an EHR vendor gets trapped into providing endless alerts.  For an EHR company, it becomes a business matter instead of a safety matter, created by potential legal liability.  If the physician doesn't read- and act- on a warning, the defense team might assert, it is not the EHR vendor's fault.  At bottom, these issues become matters of interpretation regarding what was serious and what was not serious when a legal case- or class-action suit- is initiated.  Vendors, understandably regarding their own interests, tend to be ultra-conservative, and this is especially true for CPOE of medications.

The authors suggest:

1. Increase alert specificity
2. Tier alerts according to severity
3. Make only high-level-severe- alerts interruptive

Even with such suggestions implemented, the problems are complicated since most enterprise EHR systems usually provide only globally effective solutions.  By nature, hybrid solutions do not achieve usability in specifically defined care-settings or circumstances.  The example we know best of a specific care-setting in which enterprise systems have failed to meet usability standards is the ED.  In other works, an alert that makes sense for one provider in one care-setting i.e. the ICU may not be appropriate elsewhere, i.e. the ED, nor would its intent and value necessarily be appreciated.

Some vendors have unfortunately left the job of tailoring alerts to the clinicians working at a client facility.  Dumping all responsibility on the docs is truly unfortunate, not only because it means considerable extra work and expense for the clinician staff but also because it nominally absolves the vendor of appropriate involvement in the effectiveness and up to date accuracy of the product.  The ability to do some local customization has definite value, but a balance between what the vendor inputs, and what the clinicians input, is necessary for a system to be effective, safe, and appreciated by all.

Our culture contains multiple myths and stories such as "The Boy Who Cried Wolf", and Chicken Little with the sky is falling.  Alert fatigue is a real entity and will need careful analysis to allow the positive clinical decision support to be a facilitator toward better clinical care and outcomes. 

If It Takes a Supercomputer...

Many of you may have seen recent announcements that IBMs Watson supercomputer is being recruited by hospital centers and the pharmaceutical industry and to address issues in order-entry, patient compliance, risk, and therapy selection. 

Now, you might wonder, why does medicine, at this moment, need a supercomputer?  The answer is straightforward: The practice of medicine is a complex undertaking.  We all recognize that part.  "But what about the rest of us?", you might further ask, "we who cannot afford the millions i.e. billions for Watsons' help."  Any who can afford such an assistant- as could Alex Trebek & Jeopardy, where Watson walked off with the huge prize- are not like us- everyday docs in a practice.

In truth, advances in Health-care IT , such as access to data, the internet, and an ability to simplify regular repeated procedures, have huge potential in medicine, but it is potential unrealized!  Not only unrealized, but also accompanied, in modern times, with pain.  If you are a practicing physician, no explanation necessary.  Who of you sees patients at a faster rate?  How many complete all charts before the end of shifts?  How many fire up their machines at home each night to "catch-up" on the day's work?  Who among you know for certain what you have documented without reading it over through bleary eyes?  Who doesn't wonder about medico-legalities?  Raise your hands please!

More likely your days of late have been peppered by expletives too extreme for publication here.  And this time, they've not been directed at nurses or patients...but at the machine on your desk.

Here is a simplified list of the operations a well-thought out EHR system should provide.

1. Easy access, easy navigation to necessary tasks.  Easier than a cell-phone.
2. Simplified completion of charting/medical-record creation, with very few keystrokes, and preferably with voice activation.
3. Simplified retrieval of previous work-in-progress even if others have used a terminal in the meantime- with immediate return to the previous place upon which you were working.
4. Presentation of lab, significant data on any patient being cared for with a minimum of keystrokes or clicks.
5. Background infrastructure (practice management) that allows the facility in which you work to operate efficiently, for the sake of the patient, and for the sanity of the staff.  Look- Amazon, Wal-Mart and Google do it, so why don't we?
6. Streamlined billing and collection operations that provide immediate reimbursable data to 3rd party payers, billing agencies, other insurers, and patients.

These are doable; they can be accomplished right now using simplified systems, often boutique systems (i.e. non-Watson wanna be enterprise systems).

Removal of the umbrella of baloney- meaningful use, would be a good step at the moment.  Perhaps when it is shown that medicine can address the interface between man-machine (provider-machine) practically, then the door might be open for the larger pipe dreams: sharing of data between distant facilities via standardized interoperability, and safety conscious clinical decision support and error checking.  But for now, we'd just like to get the job done, easily and correctly.  Right?

Until then, we may have to cast an outsider's eye at Watson doing SCPOE- Supercomputer Provider Order Entry, and get back to taking care of patients.

Avoiding the Potential Legal Quicksand of Opening ann Urgent Care

Opening an urgent care can be a fulfilling experience but to be successful takes more than good medical care.

The Top Four Legal Issues to Consider When Opening an Urgent Care Center article describes significant legal issues that need to be considered during the planning stages. In addition to the usual components of a business such as location, leadership, work-flow processes, and timing; the medical business has certain legal concerns.

1.       Corporate practice of medicine is outlawed in some states and mechanisms including a “friendly PC” model can be used.

2.       State licensure requirements including a CLIA certificate of waiver for laboratory testing, x-ray permits, and any other licenses needed in that state.

3.       Understanding any EMTALA requirements is key to the viability of the center. Particular attention needs to be paid to the “naming of the center”.  Adding the word Emergency will imply, the center is a 24 hour practice that is specifically under the EMTALA laws. Hospital owned urgent cares must have their legal team evaluate any responsibility to the law.

4.       Have your insurance contracts in order prior to opening or face a potential cash flow issue. These negotiations take time.

Some other issues of particular significance are:

1.       Location, Location, Location

2.       Times of service

3.       Types of providers

4.       Credentialing those providers. This is a cumbersome time consuming task which may need to be outsourced.

5.       Marketing-Establishing contact with the local community by providing school physicals, blood pressure checks, flu shots, etc.

6.       Being undercapitalized and suffering cash flow issues

7.       Picking an Electronic Health Record and Practice Management system that is efficient and pays for itself.

8.       Understanding the difference between using a billing company and doing self-billing.

9.       Hiring the right practice manager.

10.     Not expecting a “paycheck” right away.

11.     Fill in the blanks

12.     Hiring a consultant to help with the start-up, if these steps are too daunting or too much aggravation.

With a proper vision, an urgent care can be an enjoyable way to provide quality medical care. This can lead to career longevity and adequate reimbursement.

Acceptable Miss Rate

The acceptable miss rate is a concept that realizes even in the best of hands with all the available data accessible, there still will be some errors.  The question is whether society can tolerate without retribution aka law suits a reasonable attempt to keep this below 1% for most significant diagnoses.  The cost of achieving unobtainable perfection is rampant in our medical system, where depending the risk adverse psychology of the provider, the price tag goes from linear to exponential.

 

 

In the article The Acceptable Miss Rate, Dr. Jeffery Freeman states the typical psychology of most providers, "What are the odds that if I follow my instincts and send this patient home without any further tests that he'll seize and die, and I will spend the next five years defending my instincts as a defendant?"  The researchers among us may confer analytically on false negatives, prior probabilities, and Bayesian theory, but we all know what it means at a more visceral level.  But, in fact, most physicians do not spend cognitive energy calculating an acceptable miss rate.  Indeed, if the perceived odds re non-zero, it is quite likely that some justifiably preventative - defensive - action might be taken.

 

Medicine is a combination of art and science that rarely achieves 100% accuracy.  The provider trying to be an excellent clinician, following evidence based guidelines, and providing good follow-up care can still be sued, especially if there is a bad outcome.  Malpractice has on the one hand a financial cost, but on the other it also has a serious psychological cost.  This latter overhead is one that can have significant impact on the ability of the sued provider to continue delivering care while a case is defended.  Anticipatory prevention, then, leads to defensive medicine, and thus to unnecessary testing, more hospital admissions, and care that stays mired in process, without improving over time.

 

By establishing an acceptable miss rate protocol, it would allow physicians to use evidence based protocols with their experience to provide reasonable, inexpensive care.  These protocols could reflect reality of a 1-2% miss rate per specific diagnosis even in the best of circumstances.  The cost saving would be astronomical.  Moreover, the parallels between the practice of medicine and baseball will take one more step toward being acknowledged.  In baseball the batter aka provider steps up to the plate.  The patient aka pitcher throws him the ball.  The provider can watch it go by or take a swing- there really are no other options unless it is a wild pitch.  But in baseball, when a swing is taken, even those on a full team are allowed a certain percentage of errors.  Why not physicians, too?  We have yet to see a perfect baseball player or a perfect physician.

 



Avoiding the Malpractice Trap

Malpractice is back in the news with the Florida Supreme Court ruling that non-economic caps are unconstitutional.  In California, the cap will probably be adjusted to cost of living increases making it at least $1,000,000 for pain and suffering.

With the affordable care act putting more financial pressures on providers, not dealing the malpractice issue at all will lead to higher costs inevitably.  One main reason malpractice claims in two high risk states like Florida and California were semi under control - it is too expensive for lawyers to take on marginal cases.  Marginal cases equal low potential return on investment (ROI) regardless of the facts.

The trick is never getting named in a lawsuit.  Even if you win, get dropped, or the case is not formally pursued, there are still legal fees and emotional distress.  Providers are instructed to view malpractice as a cost of doing business, but most people cannot separate business reality from a very personal attach on their core identities.

Suggestions to stay out of trouble that do not include more tests or defensive medicine.

1. Keep well informed about trends.  Risk Management Monthly (no financial ties) does an excellent job.
2. Be aware that the patient is judging you on punctuality, and feels their time is just as important as yours.  A good strategy is to always apologize about the wait time even if you are early.
3. Introduce yourself to the patient and their support team.
4. Find out what brought them in today aka motivation for the visit i.e. wife insisted, worried about a stroke, death in the family, etc. Responding to their pressing need eliminates the provider didn't listen to me!
5. Allow the patient to speak for at least 60 seconds before the cross-exam begins.
6. Use the data other people have collected by confirming, not by asking the same questions over and over.
7. Verbalize the battle plan and make an estimate the time frame.  If possible, have your staff in the room for this, everyone is aware of the plan.
8. Check on the patient to see 1) if their pain or comfort has been attended to and 2) to give an update to the progress of the plan.
9. Do not tell jokes.  The patient is not sure if you are laughing with them or about them.
10. Use shared decision making, if appropriate.  Critical patients and their support team want to be consulted.
11. Give the patient very specific follow-up directions with specific time durations.
12. See a patient in a recheck as a second opportunity to get it right.
13. Document a clinical course and important conversations with patient, family and consultants.
14. Be aware of the limitations and positives of your documentation system.  Remember all entries are time-stamped.  Explain why the EKG was recorded being read at 14:00, but was read at 10:00 , especially if clinically significant.
15. When patients disagree with you and want to leave against medical advice, it behooves you to personally come to an agreement on the situation.  Delegating to a staff member is a huge error.  Make sure the patient knows they can always comeback, have witnesses especially their support members in the room, and give appropriate prescriptions for needed therapy.

Avoiding being named is the key to success.  Following common sense protocols does not increase time spent, but actually speeds up process because the patient and their support team are informed.  People sue because they are mad or frustrated.  They usually cannot determine quality care, but they know how they feel about you.

10 Reasons Doctros Are Pulling Their Hair Out

In the 2013-2014 era, doctors and providers are being asked to adapt to massive changes in their practices, businesses, and their modus operandi.  The stress from all these changes will be felt in the doctor-patient relationship.

Why are doctors unhappy?

1. Conversion of ICD-9 to ICD-10.  Nobody is sure of its value, but are painfully aware of the costs.  Having a code for a crash landing in a space craft would be relevant only for Sandra Bullock in Gravity!
2. Confusion created by the Affordable Care Act roll-out.  Not sure who's on first?  Who's covered? What's the fee schedule?  What are the new, complex rules?
3. High deductible insurance plans making payments at time of service mandatory.  Creating a new class of de-facto self-pay patients who formally were covered.
4. Acute or chronic reimbursement issues as? Fee for service will be replaced by outcome measurements.  What outcome measurements?  Who's measuring?
5. No relief from malpractice liability in most states.
6. Dealing with the Electronic Health record.  Did I purchase the right one?  The continuous moving target of getting meaningful use money. The accompaniment of possible claw backs if the data is not filled out correctly.
7. Hiring more help (scribes, medical assistants, Nurse Practitioners, and Physician Assistants) to see potentially less patients.
8. Hiring more consultants to see potentially less patients.
9. Becoming the most expensive data technician in the room.
10. Fill in the blank __________________ yourself.

 

Practicing medicine is rapidly changing and providers will have to adjust to the new realities.  At what cost to the provider and patient will be determined in the future.

PRACTICE, PRACTICE, PRACTICE!

How much education and practice is necessary to perform on cue on a daily basis consistently over the years?

Allen Iverson of the Philadelphia 76er's basketball team gave his famous version of the value of practice: "If I can't practice, I can't practice man.  If I'm hurt, I'm hurt.  I mean...simple as that.  It ain't about that... I mean it's... It's not about that... At all.  You know what I'm saying I mean... But it's...it's easy... to, to talk about... It's easy to sum it up when you're just talking about practice.  We're sitting in here, and I'm supposed to be the franchise player, and we in here talking about practice.  I mean, listen, we're talking about practice, not a game, not a game, not a game, we talking about practice.  Not a game.  Not, not... Not the game that I go out there and die for and play every game like it's my last.  Not the game, but we're talking about practice, man.  I know I'm supposed to lead by example... I know that...And I'm not... I'm not shoving it aside, you know, like it don't mean anything.  I know it's important I do.  I honestly do... But we're talking about practice man.  What are we talking about?  Practice?  We're talking about practice, man. [laughter from the media crowd]  We're talking about practice.  We're talking about practice.  We ain't talking about the game. [more laughter]  We're talking about practice, man.  When you come to the area, and you see me play, you see me play don't you?  You've seen me give everything I've got, right?  But we're talking about practice right now.  We talking about pr..."


The reality of medicine is that it takes endless practice, education, simulations, added on to experience to perform up to par on a daily basis.  The more prepared in advanced one is, they are ready to deal with most problems in an organized fashion.

Having an epiphany of insight in a stressful moment is a rare, cosmic occurrence and can not be relied on.  Bottom line, even though most of us are competent, experienced professionals we should Practice, Practice, Practice!

Value of Scribe Vs. Voice Activate Technology (VAT)

This is an interesting problem with strong advocates on both side of the equation.

After going to the recent ACEP conference, it was apparent that scribe companies are coming "Out of the Woodwork" to offset the labor intensive enterprise Electronic Health Records being imposed on most emergency departments.  Scribes cost approximately $12 - $18 per hour each.  To offset these costs, the provider must see 2 - 3 more patient per shift.  At this point with a general reduction of 20% of productivity per provider, this is not happening overall.  Providers are struggling to stay even.  In institutions where a scribe can function as a medical assistant, a "Go-For", data acquirer from the old medical records, interact with the patients, and print discharge instructions and prescriptions, the extra work is a plus.  This is how most urgent cares function with an all-encompassing medical assistant with multiple roles.  In institutions where the scribe just inputs what the provider states, they are expensive transcriptionists and typists.

Voice Activated technology is an extremely efficient alternative to transcription at much lower overall costs. The provider can dictate key components of the history of present illness and the assessment and plan- medical decision making sections of the records.  This creates a unique non-cookie-cutter chart which helps the private MD, consultants, and your own colleagues, if the patient returns for follow-up.  The problems come in where the EHR is not directly designed without a lot of work-arounds to allow easy dictation.  The initial cost is $1,500 per provider, but transcription costs $7 - $8 chart and the money is regained in time with increased productivity.

Which one is recommended?  It depends on the work flow of the ED, the EHR, and the personality of the provider.  My personal preference is a user-friendly EHR and VAT, so you can take the savings to buy more physician assistant and/or nurse practitioner FTE's.  This hopefully will lead to increased throughput, higher revenues, and increased patient and administration satisfaction.  If my scribe is an all-purpose medical assistant, this would make a reasonable alternative.

The Harsh Realities of Aging in the Workplace

One of the most difficult subjects for any medical practice is dealing with under-performance.  Viewed through its various lenses- including productivity, patient, staff and owner (hospital, etc.) satisfaction- under-performance is multifaceted and difficult to effectively engage from all perspectives.  An additional distortion is added when normal aging is thrown into the mix.

"You are as old as you feel" is a great saying.  However, if a healthcare provider does not have enough personal insight into his/her own actual competencies, normal workplace deterioration can, over time, lead to major interpersonal, financial, and professional problems.

Honesty with coworkers, employees, partners, and spouses is an idealized goal.  But such honesty- fraught with misinterpretation and potential conflicts- is rate, and seldom materializes.

Many solutions have been proposed, but a good resolution always requires creating a plan in advance to address performance and performance failures.  such a plan not only helps identify problems as they arise, but also gives concrete steps to support affected individuals, while anticipating potential snags that may appear over time.  Optimally, taking such steps as a group will get buy-in from co-workers and associates because everyone faces the possibility of such circumstances, at some point.

When a plan is not in place, steps may need to be taken.  Fortunately, some people have the insight to recognize increasing limitations.  However, others have to be firmly counseled.  Because discrimination on the basis of numerical age must be avoided, competency, rather than age, should be the basis for any action.  Age discrimination is not an uncommon claim in workplace litigation, consequently, some jobs to have mandatory retirement ages built into employment agreements.  Yet, all of us know of very senior individuals who show no signs of slowing down; and - on the flip side - we know of those whose abilities seemed to have tapered off far earlier than otherwise expected.

The best overall solution is to establish a retirement pathway, one that allows for more senior members to shoulder increased administrative responsibilities, and avoids the type of battle faced by many practices in which less experienced "Baby-boomers" wind up unintentionally in charge.  Rarely do the more neophyte understand issues that face their maturing predecessors, and the situation can become tense and uncomfortable for all concerned.  Honesty and communication are extremely difficult in hindsight; unless pathways have been created to prophylactically deal with such issues, the character, mood, and even the stability of the group can all be placed in jeopardy.

Decrease the # of Clicks and Improve Navigation

At the present time, the number of clicks necessary to fill out a chart is endlessly time consuming and non-productive.  The cost per click is now being calculated (see my prior blog) and quantified.  The work flow is slowed down and there is a real-not imagined- price to pay.

 

One solution is to create an auto-flow sequence that is tunable by site or provider and that comfortably guides the clinician from one area of the chart to another in a logical-customary- sequence.  If an out of sequence entry is desired, this should be easily accomplished.  A system with automatic guidance will eliminate the need to figure out where should one go next, especially if one is interrupted.  When it is acknowledged that one area is complete, it then moves to the next area when documentation is continued or resumed.  Once the area is completed, the list shrinks.  Your favorite click might be auto-sequenced.

 

An example sequence could be...

• Vital signs
• Triage sheet
• Past medical history
• Nursing notes
• History and PE in logical order
• Medical decision making
• CPOE
• Lab and x-ray results
• Clinical course
• Final diagnosis
• Disposition
• e-Prescribing
• Patient education
• Follow-up
• Review nursing notes
• Sign the chart

Navigation would be significantly simplified.  The provider can always go to any area directly and in any order.  Nursing notes might be reviewed, if easily accessible.  Training would be simplified and hopefully stress-reduced.

Migration Issues

 



They are various types of migrations.  We are going to focus on data and system migrations- both have many complex issues.

• Data migration- the process of transferring data between storage types, formats or computer systems.
• System migration - the tasks involved when moving data and applications from current hardware to new hardware.

A new complexity has been added to the Electronic Health Record when practices, hospitals, departments and urgent cares either transition from paper to electronic and/or change products or vendors.  The reason for change include:

1. Adoption of an enterprise system that co-opts prior vendors.
2. Adopting a product for meaningful use funds and/or e-Prescribing.
3. General discontent for the present system.
4. Lack of support from prior vendor.
5. New products have "wow-factors" the save FTEs.
6. New ownership wants to consolidate their practice to one format, etc.

When purchasing a new Electronic Health record, it is incumbent that the "migration" to the new format is planned and supported by the vendor.  These include interfaces to capture old data, scanning solutions, 24/7 support, and a firm understanding by the new provider of the various complexities.

Avoid "re-inventing the wheel" by having these discussions with all parties to provide a smooth transition.  Do not suffer from inertia- the tendency of a body to maintain its state of rest unless acted upon by an external force.  Making changes to improve productivity, work-flow are always in your best interest.

Continuing Medical Education

Staying current in the rapidly changing world of medical education, guidelines, protocols, and technological innovations is a continual challenge for most practitioners.  Having practiced since 1975, multiple reinventions of the wheel, standard of care, and now evidence-based medicine have all had their days in the sun. 

Evidence based medicine is now the buzzword for all education, but unfortunately, a lot of the data was not obtained in blinded, multi-center, prospective studies.  Much of the information is gleaned in meta-analysis format that uses flawed data as the source of their conclusions.

Treatment plans, protocols, and guidelines are far superior then in the past, but again contain "expert opinion" not necessarily the true facts.  What is left out in these plans is the "Art of Medicine".  An experienced clinician can take the best of the information and cater it to the individual patient.

How does one keep up?

1. Develop a consistent plan that teaches you what is presently being taught in the residencies and medical schools.  Take this information and adapt it to the reality of your practice.
2. Maintain Board Certification because it forces one to take an extensive review course in 8-9 years.
3. If possible, work with others.  Isolation leads to "antique practices".
4. have continuous access to the Internet at work- the former peripheral brain, or notebook in the pocket, with modern enhancement!

What to read/review?  These are what I use and have kept me pretty current.  These are not direct recommendations, but suggestions based on my specialty and practice.

1. Emergency Medical Abstracts- reviews the literature.
2. Risk Management Monthly- all the lawyers I know listen to it!
3. Emergency Medicine: Reviews and Perspectives (EM:RAP)- current real-time podcast education with practicing professors.
4. American Board of Emergency Medicine- Lifelong Learning and Self-Assessment (LLSA)
5. Medscape

Are you losing 1% of your Medicare payments for not sending Electronic Prescriptions (eRx)?

Stop losing 1% of your Medicare payments for your Medicare patients by ePrescribing their medications during their office visits.  Good news- No registration is required.  You just need to report the following G-Code on the Medicare claim form - G8553 and submit a minimum of 25 eligible eRx events between January 1st and December 31st, 2013.  You can use the following criteria to determine your eligibility.

Becoming Incentive Eligible

• Each visit must be accompanied by the eRx G-8553 indicating at least one prescription was electronically prescribed during the office visit.
• Electronically generated refills not associated with a face-to-face visit DO NOT qualify as an eRx event.
• Faxes do not qualify as an eRx event.
• Submit a minimum of 25 eligible eRx events between January 1st and December 31st, 2013.

How to Start Reporting

1. Bill one of the CPT or HCPCS codes noted in the eRx measure for eligible patient visits (Medicare Part B PFS patient face-to-face visit only qualify as an eligible patient).  *See qualifying CPT or HCPCS codes below.
2. If you electronically prescribed during the eligible patient visit, report the following G8553 code on the Medicare claim form or via another applicable reporting method.

*Qualifying CPT or HCPCS codes to be associated with the G8553: 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109

2013 eRx Payment Adjustment
Individual eligible professionals and group practices participating in the eRx Group Practice Reporting Option (GPRO) who are not successful electronic prescribers will be subject to a 1.5% payment adjustment on their Medicare Part B services provided January 1, 2013 through December 31, 2013

Discharge Module Wish List

Discharging patients in real-time should be quick, swift, and efficient.  It should not involve a labor intensive, redundant process resulting in unnecessary delay.  Completing the multiple necessary items should be possible with a few routine mouse clicks. 

Unfortunately, many of the EHRs in use today do not understand Emergency department work flow (or physician work flow and thought process in general); as a result, repeated, nested mouse clicks are often used, and these can take up to 10 minutes.  This time is better spent in actual patient care.

Indeed, many electronic health record systems do not distinguish the needs of the particular care-setting in which it is used.  Most importantly, emergency department, urgent care and outpatient settings have some similarities in their discharge processes, but for inpatient settings, discharge is necessarily more complex, especially due to recent regulatory penalties regarding re-admissions.  Hence, a "one-size fits all" software solution where inpatient discharge procedures are imposed on care-settings with rapid outpatient turnover, do not work!

One big issue with many EHR implementation is physician activities and work flow are poorly understood by IT developers, which may cause unnecessary redundancy in tasks when using the program.  Even Amazon and Google understand human ergonomics better than has been demonstrated overall by the EHR industry.  For example, instead of data accumulated by the provider being automatically transferred to the discharge information (i.e. follow-up physician, prescriptions, date of follow-up), complex actions, such as copy and paste or (worse) scanning, are employed.  This also happens in the reverse direction where data put into the  discharge paper-work is not auto-transferred, or even appended, to the medical record.  This leads to double work and difficulty in figuring out what actually happened, when reviewing the chart, if such a review of everything done is even possible.

And then, the patient often receives up to 10 pages of information with little hope of retention even if read.  It should be kept in mind that there are two basic pieces in the discharge process:  1. Instruction including follow-up plan- printed, with corresponding education provided personally by the physician and nurses, 2. Prescription - electronically created and transmitted Rx, or printed and given to the patient- including such necessary pieces as work or school excuses.

The Tenuous Balance

The EHR, Safety, and Cost

Excessive regulation & Red Tape = Increased Cost & Impaired Workflows

 

 

As the electronic Health Record marches full force to alter medicine completely, there will be some consequences.

The diagram above represents the battle between goal of patient safety, which attempts to use the EHR to solve problems, control behavior, and create new behaviors.  The problem is the end user is rarely consulted and or considered.  Government regulation forces companies to create products that decrease the ability of the end user to seamlessly integrate into their practices without the use of aids (scribes, assistants, computer jockeys, and voice activated technology, etc.).  The institutions and private practice are using EHR 1.0 and they really need EHR 2.0.  The financial commitment and government subsidies (meaningful use) create an environment of inertia that impedes rapid change to "best of breed" products.

Prolonging Your Career!

Recently I have been unable to work full-time due to medical issues.  However, it is not due to any chronic or underlying condition i.e. DM or CAD, but to a relatively sudden onset musculoskeletal breakdown.

If you saw the overweight, balding, shuffling, poor posture, and moving slowly provider, THAT WAS ME!

It has become apparent to me, that proper physical conditioning is an absolute requirement for our busy, stress-laden jobs that require of us 5 miles of walking per shift.  I worked out in a linear fashion i.e. elliptical, treadmill, and stationary bike 3-4 times/week faithfully for at least 1 hour sessions.  This did not prevent my problems.

I went to the orthopedic specialist for help with this new issue, and the first thing he recommended was taking up yoga to loosen up my totally “stiff body”.  First attending “restorative yoga” (geriatric yoga where touching your toes means reaching your knees), it was apparent that I should have been doing something like this for years.

After 2 sessions, I could now back up car safely without the use of a camera display or grab things out the back seat easily.  The classes are difficult, but improvement comes with each one.

Everybody worries about their mental health, brain power, medical health but musculoskeletal breakdown needs to be added to the list.  Yoga is a good path; some do Pilates, some intensive stretching; in any case, paying attention to, and managing, muscular flexibility and mobility is key in our profession.        

 

Which EMR Should You Purchase ?

CRITERIA:

1. Certified for meaningful use to offset costs-(includes easy reporting functions to avoid government "clawbacks".)
2. Walk up usability-(the ability to perform various functions with minimal training)
3. Intuitive navigation-(logical, consistent, and labeled)
4. Content designed specifically for the clinical area (specific charting for the Emergency department, urgent care, and/or family practice)
5. Integrated practice management - (scheduling, coding, and billing)
6. E-prescribing
7. Patient Health record (clinical data repository) that tracks Problem list, Allergies, Past Medical History, medication reconciliation, Family History, Social History
8. Ease of training-(3-4 hours vs  longer than 12 hours)
9. The program does not need multiple "work-a-rounds"
10. The use of scribes and voice-activated technology are additive,not necessary to survive

This is the tip of the iceberg. Bottom line, is purchase a product that is designed with the " End-User" in mind.

Practice Management - Requirements For Success

Many individuals are inspired to become entrepreneurs and control their own work destiny.  They are willing to put in the “sweat equity” to be their own ‘boss’.  Opening and running your own practice and or urgent care is a worthy goal but to be successful, the “devil is in the details”. 

Here are some suggestions on how to select a “value added” practice management program that allows one to run an efficient business.

1. Attractive interface that has “walk-up” usability
2. Designed for end-user not programmer
3. Easy, logical navigation
4. Scheduling module that can be customized 
5. Registration module with scanning of  identification and insurance cards capability
6. Instant eligibility notifications for insurance, deductibles, and co-pay
7. Instant access to past visits and  accounts receivable
8. Fully-integrated Electronic Health Record that interacts with the practice management system to capture all CPT codes, ICD-9-10 diagnosis to easily code and send an accurate bill.
9. Certified Electronic Health Record to be eligible for $44,000 meaningful use funds to defray initial costs.
10. Electronic Health Record that has a full database, scanning capabilities, E-prescribing, and is not “hated” by the end-user.
11. Coding support and billing functions that allow you to 1. Do your own billing 2. Outsource to a billing company 3. Any combination of the above.
12. Gives real-time feedback on AR to allow staff to resubmit claims for reimbursement in a timely manner
13. Management reports
14. 24 hours support
15. The cost of the software is offset in savings in the number of FTE’s (full-time equivalents) to run the practice.

Every practice is different, but being efficient and controlling costs goes a long way toward a positive ROI (return on investment).

Changing the Paradigm for Outpatient Care

The present model has the primary care physician as the provider and gatekeeper of patient care. They evaluate the patient, obtain consultation, admit to the hospital (the hospitalists have taken over this role), and are the general coordinators of care. However, this model in theory works well; it has proven to be ineffective. This is no criticism of the concept but the complexity of modern medicine has made this very difficult for the average family practice unit.

Current Model

The family physician is supposed be the “gatekeeper” of resources and keep people out of other venues like Emergency Departments and urgent cares.

The problem is that the general public has voted “with their feet” that they prefer the family doctor when they are well, but the Emergency Department when they perceive themselves to be quite ill and the urgent care for quick, convenient care.  Call any doctor’s office and the first non-human response is: “If this is an EMERGENCY call 911 or go to the nearest Emergency Department.”

At the present time Emergency Department Services comprise approximately 2% of the nation’s annual healthcare expenditures.

Almost every ED has the built-in infrastructure to accommodate large number of patients which could be expanded. These are centrally located in most communities and already are the de facto safety net of the United States.

Make the ED the central piece of an organized system of emergency department, urgent care, family physicians with an integrated use of consultants.

New Model

Advantages are:

• Lack of duplication of hard assets
• Patients already prefer the ED
• Coordination of care

How Medical Consumers Can Get More “Bang for the Buck”

One of the more interesting interactions between patient and provider occurs when the patient is asked, “What is the problem?”  The patient responds with “You’re the doctor,” or “You’ve got my records.”

This scenario highlights the opportunity the consumer has to achieve their goals in a quick, efficient, and potentially inexpensive way.

What can the patient bring to the interview to help the provider “GET IT RIGHT” the first time.

1. Express your motivation for your visit. Such as:
• I'm worried about a "stroke" or a "heart attack"
• I need a work excuse
• I'm out of meds
• My spouse/relative made me come
• I need a routine check-up
• My concern "runs in the family"
2. Provide a list of medications – best kept in wallet
3. Provide a list of allergies
4. Provide a list of past medical history and surgeries
5. Share what has worked for you in a similar situation
6. Don’t be afraid to say… “After Googling my symptoms, I got concerned about X…”
7. Share your expectations
8. Write a list of questions you have
9. Be straightforward with your goals -- it saves a lot of time and money
10. Reserve the right to say NO THANK You—I just wanted an educated opinion not a lot of tests and consultants.

All that said - and going back to our brief introduction of “you’re the doctor” -  what if you really don’t know.  That is, perhaps something is indeed bothering you, something is not right, but you cannot put your finger on it. 

Don’t be embarrassed.  

Doctor’s love these sorts of challenges, but they need to work alongside you to be effective at discerning the issues.  Just say it that way.  “Something is bothering me, something is wrong Doc, but I cannot put my finger on it.”  Then, you and the doctor can work together to figure it out.  And both of you feel like you have a partner in the discovery process.