Deterioration of the House of Medicine

Today's guest blog by Dr. Donald Kamens, discusses the top ten things that have led to the destruction of medical care in the 21st century. Unfortunately, the list is endless. These are in no particular order, except to say, that the next item is often more odious than the previous.  Here, then are some of things that have gone terribly wrong, and from which we seem unable to turn back.

From a doc of four decades, these are some of the forces that have served in the continual and progressive plight of medical care. Here is what I think needs to be eliminated from the House of Medicine: What do you think?

1.            DTC (Direct to consumer) pharma ads.  Think of it.  Can you remember when such a thing was actually a heresy?  Illegal?  If so, you are older (like me!). Then, the sound of a jazz guitar did not conjure up male performance anxiety and a reach for the pill. Then, all the side-effects of any drug were not spouted off by fast-talking actors, and “tell your doctor if…” were not fare for a commercial break.  Most of you know that the doctor-patient relationship is totally undermined by this crass pharma commercialism.  Ads for pharmaceuticals needs to be made illegal again. Let the doctor do the analytics and the deciding. This does not need to be a patient activity, one more closely related to recreational substances than to therapeutic medicines. At least allow the patient to choose whether to have to listen, to hear, that baloney or not. And choose whether to explore through research online or not.  In the meantime, we could let football games be football games, instead of marketing venues for various chemicals. Sure, beer is a chemical, but it is fine.  What to do:  pull the plug on greedy pharmaceutical manipulations that do well to nothing but confuse patients, and distort the role of the doctor.

2.            Barriers to doctor-patient relationship:  The prime examples here are EHR screens, creating ridiculous busy-work that makes seeing patients like filling out tax forms, and increasing pressure to see more patients in less time. Seriously?! Despite being an advocate of EHR from long ago, and an early developer, they have gone to another universe. Now we have complexity after complexity.  The EHR is such a pain, we have an ever increasing presence of scribes and other assistants assigned to deal with the clerical. Does this not attest to the progressive marginalization of the physician from the therapeutic relationship?  What to do:  eliminate documentation criteria; eliminate reimbursement based on completed charting items.  A one line should be good enough.  “Put her on antibiotics for the pneumonia, and told her to see her doctor and/or come back if not better in two-three days, or if worse. “ Not much more needed.

3.            Liability. Little more needs to be said about that nasty word, but just to be clear….here I am, on the way to work; here I am going to go help someone today.  And they often need help it seems. But wait!  I have to worry about being sued. Alost forgot! I have to think about being hurt-back by the one I am trying to help-out. Seriously?  What to do:  tort reform is not a good plan.  Why? The complexity of work-arounds would be just as overwhelming.  Simply do this: eliminate liability.  If you are there to help, you are there to help.  If you screw up, you screw up.  It is going to happen at times. The house of medicine should not allow overwhelming vulnerability, hurt to the one trying to help. Do it Shakespeare’s way, or make suing doctors illegal.  If done, the costs of medicine will go down, down, down.

4.            Reset the goals: Make patient outcome goals vastly more important than economic goals. More important than throughput statistics. Outcomes do not have to be specific (e.g. cure of coronary syndrome)...BUT Can be non-negative intermediate outcome based.  EG—the patient did not die in the ED; or the patient feels better, now, though we do not have a definitive diagnosis.  Other examples of how this has gone awry include readmission criteria -an economic goal gone haywire, causing care to be stopped before its time 2. Inpatient census monitoring - the goal should be zero census, as everyone would then be well   3- etc., etc.)

5.            Role confusion - (no one more confused than patients: who REALLY does what...doctor, nurse, PA, NP, pharmacist, unit secretary............and the ubiquitous "I never got to see the doctor"). Eliminate the vague uniforms.  Make it consistent with consistent name tags. 

6.            Stating Lies, such as health insurance = healthcare.   (Being "insured" in 2016 guarantees neither care, nor an affordable bill) 

7.            Middle men (modern medicine has seen an ascendency of middle men, not only for pharmaceuticals, but also for devices, services, etc. Too many hands in the pie, means the cost goes up, and up).  Why (Why???) do you have to have 100’s of companies trying to get a piece of the ACA or Medicare pie by offering to find YOU the right plan? Why.  Make is simple, stop this stupid spending on overhead.

8.            Fostering of unrealistic expectations - patients, very often, expect to have something available that has actually not yet been invented.  It can be a world of science fiction.  “What do you mean that your hospital cannot get/read the record from that place I was at over vacation??? “  You mean you cannot reverse my husband’s stroke?   On and on.

9.            Blindness: Here we are: what you might see does not really matter; what is recorded does.   Hard evidence (numbers & testing) has displaced observation, history-taking, examination. (Ask any plaintiff's attorney).  

10.        Stabilize the rapidly shifting medical model Pick a recent approach; stay with it as long as possible. Get ready for change.  Why?  (During the time from symptom to diagnosis may be enough time for accepted criteria for a given entity to change).  Too fast to keep up with.

#11 – 1000+ Get the EHR thing right: Look it is ridiculous to have an ever increasing percentage of time spent on wrestling with these things, time that could be used for patient care.  There are not getting better. Even the good companies know it. Government criteria are getting more and more burdensome. The absence of true interoperability is not tolerable, especially to patients who simply cannot understand why hospital X does not have the information from hospital Z. Let alone why doctor A does not have the information from doctor B at the same facility.  It is a mess. Acknowledge it.  No problem was ever solved without admitting it exists.

We're on the "Eve of Destruction"

In the song We're on the Eve of Destruction, singer Barry McGuire laments the end of western civilization due to endless worldwide strife in the 1960-1970's.  In the article The Awful (and not so creative) Destruction of Medicine, a similar argument is made for the end of private practice medicine in the United States.

The author of the article states that only 30% of physicians remain in private practice and that the "Marcus Welby Era" is long deceased.  The endless new government mandates are eliminating the private practitioner.

The physician is now part of interchangeable puzzle where everyone especially the payers have a say in the patient care and reimbursement.  The physician is no longer the centerpiece of healthcare.  The article makes a strong case that the modern day era of medicine from 1960-present is essentially over and rapidly changing.

What's a classically trained physician to do???

The best solution is to view the rapid change and chaos as an opportunity rather than a huge negative.  Realize that before Medicare started paying physicians in the 1960s that medical care was totally different.  Periods end and new approaches need to be analyzed and taken advantage of.

Potential Solutions:

1. Take some business classes or get an MBA
2. Attend some coding and reimbursement classes
3. Analyze and embrace your technology
4. The age of automatic physician entitlement is over.  This doesn't mean it still cannot be fulfilling and financially sustainable.
5. Your Medical degree is a ticket to multiple opportunities
6. Attend a meaningful use lecture or two
7. Understand that the accountable care organization (ACO) is code for 21- 1st century HMO.
8. Rethink your hiring practices.  Get professional consultations to get improved financial situations.  Hire consultants not employees.
9. Pick software that pays for itself downstream.
10. Learn the new rules and adapt
11. Realize to succeed you will need the proper software, highly trained medical assistants, and possibly voice activated technology such as Dragon to make one complete medical technology unit.

The future is still bright for the agile and well informed.  Make your theme song, The Future's so Bright, I Gotta Wear Shades.

10 Things Medical Records Won't Tell You!

The Wall Street Journal published an article last week on the 10 things medical records won't tell you.  I have condensed the list, so you get the idea...

1. COST: The price tag is HUGE!
2. SHARING IMPORTANT CLINICAL INFORMATION between providers is a myth.  Even high-price tag enterprise level systems do not do this well, or cannot, especially between different hospitals and doctors.
3. DOCTORS HATE IT in general and pretty consistently, especially if forced to use it by their hospital, the government, or partners.
4. DOCTORS HAVE LESS TIME to spend with patients...because they have to fiddle with machines.
5. PRIVACY physicians may employ strangers such as scribes to manage there cumbersome EHR into the previously sacred and secure doctor-patient relationship.
6. ERRORS MAGNIFIED mistakes are easier to make; just hit the wrong key, or have a voice recognition system hear "no chest pain" instead of "known chest pain".
7. INFORMATION OVERLOAD TMI- too much information...sometimes, in fact most of the time, we just don't need or want to read "War & Peace" on every patient, and only a section of the total is needed in any clinical situation.  But the EHR commonly gives it all. No one, especially not clinicians, have the time to read it.
8. IDENTITY THEFT EHR's contain much of your demographic information--social security, payment, address, phone, work schedule, etc.  They are therefore a fertile ground for the thieves that prey on such things.
9. YOU BECOME A MARKETING STATISTIC your information will be marketed and sold e.g. to pharmaceutical companies, insurance companies, etc.
10. BIG BROTHER IS WATCHING the government can and will track the events that occur in medical interactions through EHRs.  The requirements and criteria for this sort of tracking are already in place.

Choose an Electronic Health Record that has thoroughly considered these complaints and actively deals with them.  Complaint #10- government policies and incentives is the biggest driver in turning to EHR.

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.

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

What Will the Future EDs & Urgent Cares Look Like? --- The Remote Controlled Practice

The Big Bang Theory

The future of medicine is in a state of flux due to politics, economics, demographics, provider shortages, and consumer activism. The paradigm will need to shift to accommodate the seemingly endless demand on the healthcare industry. Expectations (realistic or not) of quality, efficient care will drive the shifting process.

I expect to see a new process similar to the one below:

1. The basic face-to-face to provider will be a “physician extender.”
2. This extender will be supervised by a “physician advisor.”
3. The physician advisor will be on location in high volume, high acuity facility.
4. The physician advisor will interact with the extender from this remote location via electronic devices for multiple urgent care practices simultaneously. On the “Big Bang Theory” television show Sheldon created a portable extension of himself through technology. Perhaps physicians will find a way to be in two places at once…
5. Consultants will be available through Skype, telemedicine, Ipad’s facetime and other such technology. Through this technology physicians can interactive with both the patient and the physician extender. A “Flow Facilitator” will be watching all the data streams and communicate with the local provider determining what to do next to achieve maximal efficiency.
6.  Artificial intelligence from EHR to take symptom complexes and PMH to assess risk of that particular patient's visit (maybe 15 years away.)
7. EHR becoming user friendly rather than onerous.
8. Patients carrying their entire medical history on their personal device.

Consumer demand will dictate a flow of patients into the system. The majority will rely on classic medical care; however, a large segment of the population will adopt an anti-technology “Luddite” approach in response to the all the available technology. They will resort to massive increases in alternative medicines.

Regardless of the quality of the care in this remote model, the “Human Touch” will always be needed to inspire confidence in the patient.

The Value of Discharge Instructions

The purposes of discharge instructions are:

• To provide time-specific follow-up with the appropriate family physician or specialist
• To  convey to the patient and/or family some knowledge of the probable disease or injury process
• To list prescriptions and treatments given
• To establish a layer of medical-legal protection for the practitioner 

At minimum, instructions need to be legible, and so are best computer generated and printed.

Unfortunately, however, unintended consequences of these efforts have evolved into a complex morass of endless paperwork.  As a result, the patient now receives a bundle of pages equivalent to a small textbook, containing more information than most people can realistically comprehend, including drug interactions, side effects, multiple contingency plans, and complex symptom sets to watch for.

The KISS (Keep It Simple Stupid) principle should predominate.  

Most importantly, the patient and family need to know that he/she should comeback, or be brought back, immediately if there is any deterioration or if new symptoms have developed. This bottom-line principle message needs be stated concisely in fourth grade level language, using large readable letters.

Doctor Aware” - The Integration of Nursing Notes and Physician Documentation

How does the provider keep track of the nursing notes with the use of purely electronic medical records?

         

Theoretically, in the “paper world” the provider would read all the nursing notes and then comment or appreciate the content. In reality, the provider rarely reads more than the initial triage assessment and nursing note. The rest of notes are kept with the nurse and usually completed long after the physician is finished with their documentation. Physicians who document after the fact on their own time, may or may not use or have access to the notes.

         

In the “Electronic World” the provider rarely has real-time access to the nursing notes with a single mouse click. They have to maneuver around the program to find the data (if it even there yet). Your computer program should have easy access of all data to all providers that have been granted access. This should be accomplished easily and without requiring the user to be a computer expert.

Additionally, how do healthcare providers know when the nursing notes are complete concerning the interaction with a specific provider? The notes can go on and on for “ED Boarders” when the initial provider is long gone. This is also true for discharged patients when the nursing notes are done long after the fact.

My favorite nursing notes are “Doctor aware” and “Doctor notified”. About what?????

The EMR we use attempts to solve some of these problems with simple interface like a “tab button” that allows quick access.

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.

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.