Saving for a Rainy Day

Saving money for retirement, legacy, charitable giving, and lifestyle can be extremely difficult for most people. My peer group suffers the “Disease of Fixed Expenses”. This is where all the bills and obligations need a certain # of dollars every month to break even. Avoiding this trap with family, relatives, and other financially demanding types at your heels is not simple.

The article Six habits of successful investors gives basic common sense advice that is universal.

1.	Develop a long-term plan—and stick with it.
2.	Be a supersaver.
3.	Stick with stocks, despite volatility.
4.	Be diversified.
5.	Buy low-fee investment products that offer good value
6.	Focus on generating after-tax returns.

   

Creating a savings plan that everyone (your entourage) agrees to is the first step.  Fully fund your Roth IRA's, 401Ks, other pension obligations before you spend any dollars.  Prepare you budget with the money left over from the savings plan, not the opposite directions or there will never be any.

Your savings on average will double every 6-8 years depending on the prevailing interest rates and net returns on your investments. If one could save $100,000 by age 35, one would have $1,600,000 at age 67 by leaving the money alone.       

The greatest misconception that many have in our shoes derives from an absence of financial education. Most of us had none. There is the simple fact that most, therefore, do not get, and if at all, not until too later in life:  money saved, can actually work for you. Yes, that is it. That is correct. Money in the bank can do the equivalent of shifts for you.  In 2016, one million dollars can reasonably bring you in $5000 a month; two million dollars can bring $10,000 and so on.  And when you are in your 60s and 70s (yes you might actually live that long), not having to work those shifts is a blessing.  Think about it: stored work.

The biggest mistakes that my colleagues and I have made concerning retirement are.

1.    Conspicuous consumption

2.    Divorce

3.    Unnecessarily expensive cars (try a Saburu-80-90% of a luxury car)

4.    House poor

5.    Thinking that your home equity is your retirement money. You still have to live somewhere.

6.    Forgetting you will probably live more that 18-20 years past retirement without a check.

7.     Setting limits on your entourage. 5 cell phones and 4 cars can add up.

8.    Severe illness can wipe you out.

9.    Costco $10-15 wine tastes almost as good the $50 wine after the first glass.

10.   Not staying in good physical shape

11.   Etc.

12.   Etc.

In conclusion, save while you are young.

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

To Err is Not Just Human

In the article How to Eliminate EHR-Based Medical Errors, presents a list of computer errors that affect patient care. While many tend to blame poor programming and software glitches, these developmental issues are only partially to blame. The ultimate culprit is a lack of standardization in EHR systems, in general. Sufficiently standardized systems would make it possible for a physician to enter data at one hospital, and when at a different one, use the very same methods.

 

Unfortunately absence of standardized interfaces is ubiquitous in our currently technological society.  For example, how often does one go to one store, say a grocery store, and when trying to pay for goods, has to deal with a card reading device that is entirely different from the adjacent store.  One has to figure each one out independently. If spending too much time shopping, one could easily run into ten different interfaces.  Quite maddening.  But that is the normal world, one would expect better of medicine and medical technology. Or is that expecting too much?

Some examples of the confusions encountered include:

1.  Data base/CPOE’s (computerized physician order entry systems)have inconsistent dosing for medications, or manages to switch the dosing between 2 medications
a.  Solution is national data base for CPOE. The data base can “live in the cloud” and be accessible to all

2.  Artificial intelligence that is artificial but not intelligent, such as incorrect weight adjustment for natural growth
a.  Solution –data base that is accurately age and weight adjusted and that catches irregularities and sends notification.

3.  Failure to inform clinician of critical lab information is a major problem.  The more clinicians are depending on technology, the more they naturally depend on them to flag problems.
a. Solution –warning system of critical lab results---coordinated through a national data base for national CPOE, mentioned above.

4.  Prescription with wrong decimal point for dangerous medications. Deadly !
a.  Solution—standardized CPOE/Pharmacy and automated safety testing.

5. Duplicate patient records.  How difficult is it when Patient Sam Q. Brown enters and registers as Sam Brown.  But the computer is thrown off by the absent Q…..and then a second record is created, one that does not have all the important information that Sam Q needs to have in place.
a. Database error created by expected variance in human nomenclature. The error should be trapped and the medical team prompted to sort it out and reconcile the records. Google does this, why can’t medicine.

6.  OUTPUT is “Gobblygook” at best. A combination of typing, cut and paste, macros, mini-macros, and  “computerize” that makes no sense. The inputs are all given the instruction to create text. There is no instruction set that can be made which will create automatic meaningful text.
a.  One solution may be greater use of voice recognition. For example, Voice Activated Technology (Dragon) allows a clinician to dictate several common sense sentences about what really happened during the encounter.  Siri does pretty well on this too.  Apple, Dragon do it, why not get medicine more fully on board?

7.  Scanned documents sent to wrong patient.
a.  No fail safe mechanism exists for stupidity or incompetence

8.  Action items never were seen or acted on by the clinician.
a.  Programming issues/inappropriately mild alerts can be blamed, often
b.  Often, it is difficult for a provider to comment on action taken because there is an inability to easily add addendum.  Developers should really try to make the systems at least better than paper in this regard.

The fundament problems are lack of standardization, easy navigation, appropriate warnings, and ______________ fill in the blank. Meaningful use money would have been better spent on a national data base and CPOE. Each vendor could then create their own system with built-in universal knowledge, integration, and interoperability as a baseline.

Danger of "Burnout"

According to the Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout greater than 40% or 2 in 5 physicians are suffering from “Burnout”. The article in graphic form is worth analyzing.

The data in the article presented below should be read and appreciated.

The main data points are:

1. Emergency physicians are at the highest risk (59%)
2. Interestingly, Psychiatry and mental health practitioners were less at risk, but still above 40%. 
3. Major causes were:

• Bureaucracy
• Too many hours
• Alienation
• Computer/Electronic Medical Record Issues (affect 1 - 3)
• Reimbursement issues
• Specter of malpractice

The data can be understood using the legal term res ipsa loquitur Latin for "the thing speaks for itself".  In other words, it does not take deep analytics to see that the practice of medicine is not as fulfilling as it was in the old days.

`What can be done? A common denominator that links all this dissatisfaction is the endless and laborious need to document using computer platforms that are not developed by those who do not understand the issues facing clinicians. Most enterprise systems are heavily weighted to maximize billing effectiveness. The clinical side of these large systems sits on that foundation. Clinical needs are thus generally ignored, unless, of course, they impact cash flow for the clinic or hospital. A good sports car cannot be built using the infrastructure of a battleship. Fix this chronic overwhelming burden and medical practice will become a combination of science and art that would make clinicians happy, and put the fire-hose to the burnout.  

The Value of Backing Up Your Electronic Health Record with a Fail Safe Plan

The Gazette reported, the University of Iowa’s Electronic Health Records went down to a server problem that lasted six hours. The problem was resolved quickly. Keep in mind that for a busy ER, six hours is NOT quick! 

The main problem is what to do during those hours of downtime. A back-up system that is not on the same server can protect the data and mostly protect the patients from inadvertent errors. These errors can lead to poor outcomes, loss of crucial information, and potential liability.

Installing a stand-alone back-up system that is easily used and can be later scanned into the Enterprise system will save time, money, greying hair and endless stress. The occasional power failure will be survived with minimal cost and avoid the “group insanity” that’s accompanies these events. 

Hospital systems should write a guaranteed functionality clause into contracts for EHR implementation.   It is the enterprise vendor that should assure their system continues despite potential catastrophes.  After all, it is during catastrophes, environmental stresses, and local disasters, that the continued operation of the ED is most needed.  Thinking about the inevitability of such events in advance is essential, and should always be a part of the EHR package.

“Meaningless Use” Stage 3 To Disappear?

In the article AHA to President-elect Trump: Cancel Stage 3 Meaningful Use, the American Hospital Association make a plea for the elimination of meaningful use Stage 3. AHA calls for focus on EHR interoperability, interoperable health IT infrastructure instead of demonstrations of certified EHR technology use.

 

The unstainable regulatory burden which includes MACRA (Medicare Access and CHIP Reauthorization Act) is unrelenting and cost ineffective.  Reading this article will help providers understand what they may be facing with the coming confusion of MACRA.

[MACRA = Medicare Access and CHIP Reauthorization Act, a 2,400 page rule which establishes new ways to pay for physician services to Medicare beneficiaries, and will be likely extended to all insurers as well. MACRA reimbursement will be based (in theory) on quality, resource use, clinical practice improvement, and meaningful use of certified EHR technology.  Ever heard the term “Meaningful Use” before?) This includes an effort to base payments on outcomes. Of course outcomes require measures to be assessed.  Payment changes are scheduled for 2019]
The AHA makes multiple recommendations that are favorable to hospitals but not necessarily providers that make reasonable sense.






“Advance health IT by supporting the adoption of interoperable EHRs, promoting a more consistent use of IT standards and providing improved testing, certification, and transparency about vendor products.”

Bottom line is that all the billions of dollars spent on meaningful use to capture endless data points that have little value to the average practitioner, this has created significant burden to cause acute on chronic “burnout” leading to chronic dissatisfaction.
The money spent could have been used on a robust national database that would have been the basis for Electronic Health Records interoperability. This would have included a national computerized order system that ended the hours relearning multiple systems.

From an EHR provider point of view, these rules have squelched creativity, efficiency, and what should have been a positive clinical adjunct into minefield of clicks and workarounds. When one adds the various meaningful use rules to the EH R, it significantly damages the EH R usability experience. While the Electronic Medical Record with artificial intelligence will hopefully someday be looked at as an asset, the barrier that interoperability imposes has yet to be solved. Why? 





Currently it is not in the interest of any EHR vendor to make their system interoperable.  Why should they allow a small (quite inventive and easy to use) system work well with theirs?  The large enterprise-level vendors have long suppressed interoperability efforts, while the smaller, creative ones, and have pushed for it. Such activity is not uncommon in the tech world.  Roku was once a small company too, and look how they have impacted the cable companies. But interoperability suppression is in no way appropriate in health care.

 

 

For Every New Medication 2 Need To Be Removed

One of Donald Trump’s campaign promises is:  “I will formulate a rule which says that for every one new regulation, two old regulations must be eliminated.” No matter what you personally feel about the new president this idea makes a lot of sense.  Many would be happy with just “no new rules, period!” But the 2 for 1 rule (a two-fer) can easily be transmitted to multiple other areas of consideration, especially in pharmaceutical realm regarding prescribing of endless medications without making the critical decision to eliminate any.

Problems with side effects and medication reactions plague the elderly and/or chronically ill patient who carry or store suitcase full bins of pharmaceuticals. Compounding this, when more than one doctor is involved, they rarely decide in concert what to use, and multiple treatments from a stack of practitioners often lead to serious consequences.

The article Adverse drug reactions in the elderly author quotes, “Medications probably are the single most important health care technology in preventing illness, disability, and death in the geriatric population. Age-related changes in drug disposition and pharmacodynamics responses have significant clinical implications; increased use of a number of medications raises the risk that medicine-related problems may occur. “

The number of patients suffering from polypharmacy, significant adverse reactions, and admissions to the hospital is significant and radically increases with age. Many are dose related which alter blood levels of potentially beneficial medication; these can then become life threatening. A good example is blood thinners whose pharmacology can be affected by multiple contemporaneous common medications like antibiotics or ulcer medications.

In a prior blog, a semi-tongue-in-cheek approach was suggested: if the medication bag was too complicated to list easily then the bag should be weighed, discarded and start new treatment plans from scratch. It is not a bad idea. Why weight it though? Some kind of list should be made before tossing that considers what symptom or problem the pharmaceutical is supposed to address. Then after tossing the bag, one can see if each problem still exists, and if a therapeutic avenue has been taken with the new medications.

In conclusion: many seriously ill patients need multiple medications to survive but after too many, a situation of diminishing returns sets in, and side effects often become more serious than the original problem. Maybe, after 5-6 medications are prescribed for chronic complaints, a serious analysis of the need for “all” of these treatments needs to be done. Taking unnecessary medications can be dangerous, create new clinical problems, and dramatically increase the expense of care. Adopting a policy similar to the regulation policy suggested in the beginning may be a good start.  In fact, any individual on more than 5 medications deserves a review on a regular basis, with the intent of eliminating any that are either ineffective, dangerous, or in excess.