The Rise and Potential Consequences of Using Advanced Practice Providers

Utilization of APPs (advanced practice providers) or MLPs (mid-level providers) such as nurse practitioners and physician assistants, has increased geometrically all across the medical field. The APPs have filled huge gaps in medical care and have performed quite well. However, with growth comes the concerns and responsibilities of supervision, training, continuing education, and liability.

The recent article Medical Supervision of Mid-Level Providers written by a malpractice insurance company contains an extensive list of concerns. They are:
·         Ensuring proper credentials.
·         Delineating scope of practice.
·         Being sure a MLP’s clinical activities do no exceed the supervising physician’s Clinical privileges.
·         Teaching sufficient communication skills to the MLP.
·         Conducting regular and periodic reviews of the MLP’s activities and clinical responsibilities.
·         Encouraging each MLP to seek supervising physician oversight as needed; encouraging questions.
·         Require MLP badge identification to make credentials clear and avoid misunderstanding.
·         Provide patients a mechanism to access the supervising physician, if they choose or request.
·         Be familiar with local laws related to the scope of practice and supervision requirements for MLPs.
·         Be sure each physician who oversees MLP activities is authorized/approved to provide supervision.
·         Ensure that the MLP is properly trained for the nuances of your individual practice setting.
·         At least yearly, review/update MLP job descriptions, policy statements, practice protocols, collaborative and employment agreements.
·         Keep a copy of the collaborative agreement on file in each practice location where the MLP works.
·         Develop and approve guidelines concerning prescriptive practices. At minimum, the guidelines should:
o    Identify the supervising/collaborating physician(s);
o    Identify the types of medications to be prescribed as well as limitations;
o    Define provisions for managing emergencies; and
o    Specify the frequency of reviewing prescriptions written for controlled substances.
·         Regularly review and update protocols for frequently encountered clinical problem(s).
·         Plan scheduled meetings with each MLP at least monthly for the first six months and at least quarterly thereafter or as often as otherwise required by state-specific requirements.
·         Document any clinical problems discussed and a plan for improvement.
·         Be sure that professional liability insurance includes coverage for MLPs.
·         Contact your malpractice carrier immediately whenever adding MLPs.
 
While this may seem to be quite an extensive list, it is actually the same general conditions under which most physician providers function. Additional suggestions are:

1.    Make sure that the chain of responsibility of the supervising physician is specifically spelled-out, and understood by all.

2.    Be careful of having different malpractice vendors for MLPs and supervising physicians. This can generate adversarial situations when a case appears.  
3.    Have clear, specific policies regarding when the MLP should ask for an immediate consultation.
4.    Make sure APPs do not identify themselves as doctors, even if one has a PHD. Juries are sensitive to potential misrepresentation.
5.    Send your APP to specific courses for the care setting in which you work. Remember how practical knowledge comes with time, but is not innate.
6.    Understand your malpractice coverage. A consultant may help make sure everyone is adequately covered. The APP needs to be named on the policy.
7.    Have a cordial and professional relationship with your APP.
8.    Avoid allegations of fraud by following CMS billing guidelines; your degree of clinical involvement in any case should never be overstated.

Times are changing and it is important to adapt to the new realities. The Advanced Practice Provider is the political answer to lack of access to health care for the near future.

Motivation for Building a “McMansion”

In the article one weird reason why doctors buy bigger homes than lawyers, it explains a seemingly common practice in locations in certain tax protected states that physicians purchase more expensive homes to protect their assets from malpractice liability.

The article states that doctors buy bigger homes than lawyers in general.  Protection of assets by buying an expensive dwelling in place like Florida and Texas is a well-known strategy that many people in the top 5% use very creatively.  There are multiple homes sitting on the coastline with few regular dwellers. A former commissioner of baseball used this strategy quite effectively. 
The sad part is that people have to go to such lengths in our litigious society to protect their lifetime assets and protect the future of their families.

A seemingly simple solution for the medical profession would be to radically alter the malpractice system from a personal fault system to a reasonable no-fault system that compensates the injured appropriately. It would also punish egregious repeated behavior by some practitioners through appropriate sanctions. Other countries like New Zealand have accomplished this with some success.

The ultimate solution is not to get sued either individually or in a group. Unfortunately, the odds are against you. On the other hand, a nice house on the beach is nicer than living in a tent.

Avoiding Retirement Planning Mistakes

Entering retirement is potentially a time of less stress, reinvigoration, reimaging oneself, travel, and reinventing oneself. The major problem with this is it takes enough money to navigate retirement comfortably.

 

The article Top 10 Retirement Planning Mistakes lists 10 technical reasons that lead to poor planning and execution. The big ones are not saving soon enough, not anticipating inflation and taxes, unpredictable medical expenses, retiring with excessive debt, and not understanding the rules of disbursement of funds.

Social Security and Medicare should not be the cornerstone of any retirement plan but an adjunct.

My associates and I have made significant errors in planning, predicting the future, and learning how to live on a budget.

The following are some classic errors to which I am party to many.

1.      Not realizing you may live 20 years past retirement.

2.      Owning and still paying off expensive homes and cars.

3.      Paying everybody else’s bills. The children though grown are still on the dole.

4.      Not saying “NO” to everybody on your payroll.

5.      Not treating the disease of fixed expenses before it is too late.

6.      Getting divorced.

7.      Thinking retirement planning is not a dynamic enterprise, but due to longevity changes from year to year.

8.      Trying too hard to leave a decent inheritance. Informing your relatives that any money spent now is money they will not get in the future.

9.      Getting off the endless need to buy more and more. If you shopped in your own closet, you will find things that are back in style.

10.   Avoiding get rich schemes.

11.   Establishing limits on credit card usage. Calculate how much money a person can spend a day. This brings harsh reality to bear.

12.   Not staying in physical shape.

13.   Not getting help in picking the best Part B Medicare supplement as the cost differs wildly.

14.   Getting advice on when to take your social security check. This is a very individual decision.

15.   Going out to dinner instead of lunch. Lunch menus are significantly cheaper. Drink at home.

16.   Learning the rules of mandatory distribution of IRA’s at 70 and ½.

17.   Not divesting your investments in a common sense orderly fashion. Certain investments should be liquidated before others.

18.   Not warning your children that you may have to move in with them if they keep asking for money.

19.   Not leaving a will or estate planning. If you hate your family, this is a good plan.

20.   Being realistic about potential health costs. Even healthy people can easily spend greater than 6 figures their last year of life. Hopefully your insurance will cover this.

Bottom line is to enjoy life and retirement. Do not be plagued with the constant worry of money. Remember, your relatives and dependents can always get a job.

Using Yoga (or Pilates) to Restore Your Health

The article Restorative Yoga Poses articulates with pictures how to restore the body and maintain and improve fitness.

Yoga can be used as an organized way to improve strength, flexibility, balance, psychological relaxation, and a way to age gracefully.

When walking by a yoga class, the first impression is that you have to be really fit to participate and you do not want to make a fool out yourself. The reality is yoga practice is on a continuum and changes according to your level of experience and fitness.

The biggest challenge is walking in the room and participating. Nobody is watching you except the instructor and the practice is an experience not a competition.

A new student will quickly discover how out of shape they truly are and the potential for fitness, weight loss, and stress reduction. I am usually the fattest person in the room and have lost >20 pounds in 2 years. My balance is dramatically improved and twist sufficiently to back the car down the driveway.

The advantage of a class format is that the most unmotivated person’s challenge is only attendance. The fitness workout takes care of itself. The upper body, core strength, flexibility, and lower body strength will automatically improve over time.

I wish I had begun when I was fifty and not waited till Medicare age. This can be a senior citizen’s panacea to chronic pain, equilibrium, balance, and terrible upper body strength. Start with a few restorative classes and easily progress to better health. The spiritual side can be a life-guiding support system and can easily add to the improved physical health.  

For those who do not wish to incorporate a spiritual component within their exercise program, there is the equally restorative Pilates, named after its founder Joseph Pilates.  Pilates training is very available, perhaps even more-so than yoga. All of the benefits noted for yoga apply. While some Pilates exercises require use of devices (the main one called a “reformer,” though it has nothing to do with discipline!), there are also mat Pilates exercises that can be learned online (YouTube), which can easily be performed in one’s living room.

Whichever you choose, Yoga or Pilates, it is wise to take a bit of time each day to pursue one of these, especially as aging advances (which it does!).  These two body-training programs will help keep you sane, flexible (in body anyway), and able to negotiate gravity, which (regardless of its newfound waves) seems always ready to find ways to trip us up.  Be wise, have fun, and pick one of them.

Disposition Driven Test Ordering/A Change in Paradigm

The most common complaints about Emergency Care is cost and inappropriate utilization.

The Sensible Test Ordering Practice in an Emergency Department report was published by a pathology magazine, and provides the STOP methodology to reduce the # of coagulation and glucose testing most of which do not affect outcome and or treatment. A major problem seen from the viewpoint of these authors in the lab (pathologists) is the classic rationale for test ordering, which consists of ordering packages of tests that (if negative) do not affect outcome. Ordinarily this happens for the sake of consultants, completeness, diagnostic uncertainty, usual practice, training dogma, and liability concerns.

Analyses of this sort don’t get the principles that truly apply in emergency medicine, and those principles are based fundamentally in clinical judgment.  Is it the responsibility of the ED doc to save money, or potentially save the life and health of the patient?  When standing in the pathology lab, any negative test appears to have been unnecessary. 

On initial presentation, the ED doc is confronted with a unique chance to impact the care of any patient.  If he/she has seen a hundred patients and cast the “wide net” of a “routine” set of lab tests, receiving, say one or two with a positive result that impacted life, but 98% or 99% are unnecessary, is this type of pathologist’s perspective really of value?  Ask the patients who were impacted.  No wonder that getting out of the “routine order mindset” is a daunting task. The article shows how difficult and complex getting rid of a “low hanging fruit” test is. Low hanging fruit is fruit because sometimes, just enough times maybe, it makes a difference. But is testing practice really a result of mindless habit?  Or could it be experience and concern for the patient driving such testing?

It would be “politically correct” to suggest that the Emergency Department Provider change focus and order only tests that directly affect patient safety and disposition. How realistic is that?  In truth the ED doc, when first seeing a patient stands at the gate of a large city, looking for a place to live.  Since real estate is specific, finding the one that fits requires casting a larger net than other providers do.  Of course, understanding red flags and high-risk situations can deliver the provider to a quick risk assessment of most problems. But not every important flag is red, nor are all situations high-risk today, that will become high-risk tomorrow. Ask any plaintiffs lawyer. Then factor in the true cost of limiting testing from the pathology suite.

While the provider might be counseled to focus on the 1 or 2 tests that clinch the diagnosis, determine the disposition, and send the patient down the proper pathway to health, this paradigm ignores entirely the patient whose disease process would be found through other testes.  And certainly, limiting tests to the “money tests” will decrease costs on the set of patients for whom they are limited, but not for the system in which misses will naturally increase. 

An example of a restricted test protocol would be:

The provider would be given:

1. the vital signs with pulse oximetry
2. EKG if indicated
3. The option to order 1 or 2 tests maximum
4. Upon receiving the results of those tests the provider can discharge, admit, start treatment protocols.
5. If the patient is critically ill or immediately falls into a specific treatment protocol, these can be initiated. The treatment protocols include all the tests anybody would want.
6. Time hopefully would be saved due to rapid disposition of the majority of patients who were concerned about very specific problems.
7. Likely however, time will be lost in total because there will be significant number of doctor-patient combinations where sufficiently clarified status is not obtained by limited testing, and repeat, after repeat, after repeat keeps the patient there for hours (and hours, and hours)
8. On the one hand, when successful, down-stream costs with endless consultations may be avoided. On the other, the costs will HUGELY accelerated in those cases missed.
9. The ED is a unique opportunity, especially for the many who have no other access to care.

Examples:

1. Patient has chest pain. EKG + for Acute MI. Disposition would cath lab and MI protocol. (The authors would not check the INR, if the patient is on warfarin, and if the INR=50, that patient will likely not exit the Cath lab).
2. Patient has severe abdominal pain. CT-neg. Clinical reevaluation then discharge or admit. That would be fine if inter-observer reliability was present. It often is not (Br J Radiol. 2012 Sep; 85(1017):e596-602. doi: 10.1259/bjr/95400367.)
3. Patient has head injury. CT-neg.  Clinical reevaluation and disposition. (but you missed the leaking aneurysm)
4. Patient has sore throat.   Treat.  Reevaluate if no improvement. (Did you catch the epiglottitis?)
5. Patient has severe cough and fever. CXR-right lower lobe infiltrate. Reevaluate clinically and discharge with appropriate prescription or admit with pneumonia protocol. (ah…yes, forgot the CT scan, and the patient returns dead after multiple pulmonary emboli)
6. Patient with weakness. EKG shows u-waves. Get electrolyte package and treat. (ah sure, treat for hypokalemia, but did you remember that u-waves can be sign in subarachnoid or intra-cerebral hemorrhage)
7. Patient with low-risk chest pain. Troponin-neg, EKG normal. Repeat troponin 2 hours. Make disposition. (that’s the one whose pericarditis you missed because you did not do a CXR)
8. Patient with possible stroke. Depending on distribution of symptoms get MRI or CT. Start treatment protocols if indicated (don’t forget the coag profile!)
9. One of the most important clinical tools one can develop happens when one makes oneself record (write-down) the results anticipated for any test. This was taught to one of us by an illustrious grandfather of medicine shortly before he died.  The lesson was that by doing so throughout a career, dependency on tests would decrease. One’s clinical insight would gradually increase, and the path to a correct diagnosis would be much quicker.  It works. And it is a much better approach than simply STOPing the test net.
10. The approaches suggested from the pathologist Labe are intended to save a lot of upfront costs, admissions, and hopefully downstream costs. Do they really save time???  Save lives, save morbidity? Theoretically they should. But the misses are simply left out of the picture. And those have extreme costs to both the patient, the doctor, and the system.  Bottom line: take the time to hit a “home run” rather than run the count to 3 balls, 2 strikes on each patient before making a disposition. Home runs require hitting all the bases, you know.

The Beach Boys - I Get Around - Workarounds

In the recent article Targeting EHR Workarounds, the author makes the following comments: Workarounds, depending on the system and the user, might be harmless in some cases but potentially dangerous in others.

 

Whatis.com states the definition: A workaround is a method, sometimes used temporarily, for achieving a task or goal when the usual or planned method isn't working. In information technology, a workaround is often used to overcome hardware, programming, or communication problems.

The fundamental problem is that these workarounds may solve problems, but may inadvertently create hidden/unknown downstream issues.

1.      Potentially created by a non-authorized user, circumventing safeguards
2.      Putting the facility, the user, and the supervising hierarchy at liability risk
3.      Affecting data collection
4.      Missing financial credit for the documentation
5.      Missing data qualifying for “meaningful use” credit
6.      Potentially using macros with cut and paste that obscure the individuality of the encounter
7.      Potential fraud issues as to what discussions and acts were actually performed.
8.      Very important: avoiding definitive resolution of the issue. That is, by taking the workaround short-cut, and not communicating with the vendor about the problem (sometimes easier said than done), it will continue to appear for everyone.
9.      Customization may be creative but cost-prohibitive.
10.  ETC.

Many workarounds are designed to avoid alert fatigue. These may do the job most (99%) of the time but can be disastrous if key information happens to be ignored at a crucial time. See our prior blog on “Alert Fatigue”.  For example, scanning-in of relevant documents (say, a medication list) may make life apparently simpler, but if physician eyes do not see a key item (e.g. warfarin) the EH R and its decision support mechanisms will be missing critical data (so, the patient may bleed to death if sent to surgery without anticoagulant reversal).

 

Workarounds are most often created by the most innovative and intelligent clinicians among us (and the ED seems to have it share of them), trying to overcome tedious workflow issues in their E H R.  Many are guilty of discovering and using them. No names will be given. Unfortunately, however, the problems noted above can (and have) come back to haunt the provider and the facility. The best solution is find an EHR designed specifically for your area of work and engage the vendor in a continuous process of making the product more user-friendly. In that way, workarounds can quickly become a principle source of EHR and workflow improvement. “Workaround types” would enjoy listening to the Beach Boys classic –I Get Around.

Which is Worse? Malpractice Case or Medical Board Investigation

The Black Cloud of a Medical Board Investigation is a must read for practicing professionals. The title speaks for itself. A referral to the medical board of your state can turn into a complex nightmare scenario in which you can be viewed as guilty until proven innocent.

To limit damages, targeted providers are forced to hire lawyers at their own expense to hopefully limit damages. Even though most cases are resolved quickly, even these can easily cost $20,000 and up in legal fees. In our experience, medical board actions have been as costly, as high a career risk, and as stressful as a malpractice suit.

The cases that go “south” can lead to summary suspension of license, difficulty in obtaining malpractice insurance, getting on certain insurance plans, dismissal from a hospital staff, and getting a “strike” in a 3 strike (3 strikes and your out) state like Florida.

Unfortunately, complaints are easy to file. The accessibility of filing by everyday individuals has made these actions much more common than malpractice suits. To make matters worse, accusations can morph over time and can be resubmitted multiple times if a patient or family does not get their desired result.

Medical boards receive many different kinds of complaints. Some are extremely serious (see below) but it has been found that most board actions are a result of poor communication and poor interpersonal relationships.

The most serious kind are designated sentinel events. According to the Joint Commission, a sentinel event is “and unexpected occurrence involving death or serious physical or psychological injury, or risk thereof.”  They are called sentinel because “they signal the need for immediate investigation and response. 

Ordinarily, these types of incidents get reported to the Medical Board by the critical incident committee of the hospital.  Although relatively minor events can qualify as sentinel, more frequently they are about major events and wind up being appropriately referred from the hospital to the board.  A significant proportion of these complaints are initiated by unhappy families who want “whatever they perceive has happened to their relative never to happen again”. Those who work with such cases know that perception and reality are not always identical in many situations.

While most providers are understandably paranoid about malpractice and/or liability issues, they nevertheless need to educate themselves about medical board practices in their states.  The potential adverse effects of a board investigation are not to be taken lightly. Both type of incidents, malpractice allegation and medical board referrals, are serious events that can be life-changing. Hire appropriate experienced counsel to help you survive the process.

Good patient communication, positive interpersonal relationship, and excellent documentation will help prevent both malpractice claims and board referrals. Good documentation does not have to lengthy, but when it is goal specific and captures the essence of clinical interactions, it can be life-saving (and career-saving) if confronted with either type of incident.