I have had a love hate relationship with our computerized medical record since we first started using it in 2007. Much like computers in all of American society, the idea that our computerized medical record is just a small facet of what we do, involved in the storage of information, is a gross simplification. In the US (also elsewhere, but I can't speak for Europe or Asia from much personal experience) the ubiquitous presence of computers has affected how we work, play, think, communicate. These interfaces with brains that we use so frequently have made us fatter, more connected to each others' thoughts, less connected to each others' bodies, has reduced our ability to use non-visual senses, has partially convinced us that 3 dimensions are optional, and I could go on for hours (at which time all hope of going out for a walk would be gone.) In my medical office, my near-umbilical connection to my laptop has touched all parts of what I do. The production of a document, which integrates information from as many sources as I am aware of that refer to my patient, is one of the most important goals of a visit. I also try to solve the patient's problem and answer their questions and listen to them, but I do it within the context of my computerized medical record. This sounds overstated, but in my particular case I think it is pretty accurate. So the fact that our particular software package sucks is profoundly irritating.
Now "sucks" is a pretty strong word, and I only use it because we just had an update which has been as infested with bugs as a cheap motel and I am frustrated. Oh so slow. I feel like some sort of a bivalve sea creature as I wait for the screen to allow me access to my patient's vital information. I feel trapped and claustrophobic as I attempt to stay within one layer of the record while needing simple information such as what happened last time or how old they are, that exists but is clicks away. The love part of "love hate" comes in when I see how many great features there are, including the ability to communicate to other doctors in my practice and support staff and pharmacies in a way that is accurate and nearly instant, and the fact that I can organize and transmit information that is coordinated and readable to the patient or to unconnected physicians in a printed format. That doesn't sound like much, though, in return for essentially marrying a computer.
I can, however, imagine a computerized medical record that I would really love, and have been doing that exercise for the last few days. I will now state what I want, and maybe at some time in the future, the universe will provide.
I would like my documentation system (EMR, for electronic medical record) to allow me to record information quickly and efficiently. I would like it to remind me to do things that I don't want to be thinking about while I am trying to concentrate on listening to my patient and formulating a reply or solution or whatever is called for. I want my EMR to keep me from doing obviously stupid things. I would also like it to tell me how late I am getting for my next patient. This is not much to ask, and I know computers can do this stuff. In fact, it may be that somebody's EMR somewhere in the world does do this.
When I first sit down with a patient, my nurse has been in the room, has gotten vital signs (blood pressure, weight, pulse, temperature) and, time allowing, has asked what issues the patient has and even typed them up in the medical record (yay Joy, you are an awesome nurse.) I would like my EMR to have already given my patient a chance to answer some of the more routine questions, such as "is this really your medication list?" and "in addition to your issues today, do you have any alarming symptoms such as passing blood or fainting or chest pain?" When I first looked at the screen it would show me a summary of the most recent medical visit and labs, so I would be reminded of salient information. I would then like to have a discussion with my patient about what they want help with and the stories, questions and answers surrounding that (the history of present illness.) I then want my computer to prompt me to ask questions about the corresponding systems. (Patient says "trouble swallowing", computer brings up review of nose throat and intestinal system "do you have post nasal drip, cough with eating, vomiting, heartburn or blood in the stool".) I then want it to remind me to review the background information: still in the same job? marriage? family history, clues to stress related issues? medical history? Then I will do my physical exam. I want it to highlight any abnormalities of the vital signs (sometimes I don't notice until later that the patient's blood pressure was elevated) and come up with a form to document my exam that is consistent with what I normally do. After I finish that, I would like it to highlight any area that the complaint suggests would need more careful examination. Then I want it to ask me what medical orders I wish to add and which medications I wish to prescribe or change. If I order a medication that interacts with another or that the patient is allergic to, I would like it to tell me (it does this now, but in such a ridiculously lame way that it is unusable). If I order a test or procedure that has been done or ordered in the last year, it should tell me that, too. Then I want it to suggest patient education handouts which I would press a button to print out. I would then tell the patient what I am thinking, ask if they had any other questions and the EMR would notify the nurse to come back in and it would lead her through a brief review of preventive medicine recommendations to tell the patient (due for a mammogram, stuff like that), but only once or twice yearly for any given patient. The nurse would also then make sure the patient had prescriptions and followup information which would already be clearly documented in the record. As far as reminding me how late I am, I would like there to be an appointment bar at the edge with present time and color coding and actual numbers to indicate how long my upcoming patients have been waiting.
Could I go through all of this in a 15 minute appointment? Depending on the complexity of the problem, most likely yes. Would the patient feel heard and supported? I think yes. I know for sure that if I spent less time in combat with stupid evil software I would have more mind and heart to spend on being a human helping another human in need.
Computerized medical records are here to stay because their potential for improvement in communication is so awesome. The most important trick is for us to make them facilitate real care of patients rather than let them suck us into their information vortex only to have us lose sight of what we as caregivers are for.
Saturday, October 22, 2011
Wednesday, October 19, 2011
Telemedicine: where could it lead?
I have only 6 more days in my present job as a primary care internist in my home town. The process of wrapping things up has been new and time consuming, but ultimately very rewarding. I get to see patients I've known for over a decade, in some instances, and review what has happened with their lives and their health and we work on future plans for maintaining what they have gained and getting a handle on problems still bothering them. We say goodbyes and good lucks and talk about the important, big stuff, like hopes and dreams and medication refills. Interspersed among these appointments and phone calls are multiple communications about my next job, whatever that will turn out to be.
I am signed up with 2 locums companies, and in contact with 4 recruiters who are my agents, as well as the recruiters that are associated with my possible new jobs. The phone calls are mostly really interesting, since I get to hear about new places and how they are doing what they do in health care. Many of the jobs that sound perfect have been non-starters because they need me at times when I can't be there, or for lengths of time that would take me away from my family for too long. Primary care positions would like me to be around Monday through Friday, with the occasional call weekend in some cases, for 3 months. This could work if they are within a reasonable traveling distance of my home and family, which does cut down on my options. Hospitalist positions, where I would take care of just patients in hospital, usually for 12 hours each day, are considered full time if I work 1 week on and one week off. If they are willing to fly me in and out, and the location is within a reasonable distance of an airport, that could work anywhere in the country. I would not have to be away for so long that my dog forgets who I am. Of all the jobs I could get, I would prefer "traditional internal medicine" which involves both outpatient and inpatient work because I think it will teach me more about a whole community and how it is coordinated to do health care. It is good locum tenens etiquette to apply for only one position at a time, which can lead to serial disappointments and presently I remain on the edge of my seat as I wait for confirmation of my first assignment. I'm sure it will be just fine and dandy, whatever it is, but it would be so reassuring to know where I will be in 2 months.
My resources for this adventure (my 2 years off from my regular primary practice) include quite a few friends and colleagues who have done or are still doing locum tenens (latin for "place holder") work. They tell me what places they have liked, where the ethics or the support might be thin, which companies take care of their clients. Sometimes they even know of specific needs, where I might work without using a recruiter at all. One such opportunity is doing telemedicine. Telemedicine is the practice of taking care of patients remotely, using telephone or computer. It is often practiced in places where the right doctor cannot be present physically, such as when a rare specialist is needed in a tiny hospital. It is used to share expertise over great distances, and is used internationally by some medical aid organizations. At the recommendation of a friend, I contacted an organization called MDLivecare, which provides telehealth services domestically, with private clients (people who arrange e-visits on their own) and corporate subscribers. A large company may wish to provide their employees with a way to contact a physician quickly, easily and inexpensively as a way to reduce time lost from work and in order to provide services more inexpensively. The telehealth visits include many of the trimmings of a real doctor visit, including documentation of what was discussed, communication with the primary care physician if there is one, and even prescription of medications (though controlled substances are strictly out.)
At some point in the future I will probably know more about telemedicine because I will probably try doing it. I have always enjoyed the challenge of treating patients over the phone, and having a video chat interface will be even easier than that. Much can be communicated verbally, and though loss of the touch aspect of medicine is a considerable hindrance to some diagnoses, I think it will be really interesting to see how much can be done in this type of an encounter.
Yesterday I visited with a patient who had a very odd neurological problem, a "funny walk" that was new and didn't really fit into patterns I had seen before. More than anything, I wanted her to be able to see a world class neurologist, who could probably ask a couple of questions, watch her walk down the hall and know what she had. But we were in a small town in a small state, and getting to a world class neurologist is probably nearly beyond her. It would be so simple, if telemedicine were more widely accepted, to call my favorite world class neurologist, web cam her funny walk, tell him my concerns and ask any questions he might have and get our answer. What presently hinders this are the fact that even practicing telemedicine requires a state license, and that there are no easy ways to bill for this service. Clearly that needs to change. We have technology at our fingertips that would reduce human suffering and we are hamstrung in our ability to use it. I look forward to the inevitable adjustments in payment schemes and regulations that will allow us to use what we have to its best advantage.
I am signed up with 2 locums companies, and in contact with 4 recruiters who are my agents, as well as the recruiters that are associated with my possible new jobs. The phone calls are mostly really interesting, since I get to hear about new places and how they are doing what they do in health care. Many of the jobs that sound perfect have been non-starters because they need me at times when I can't be there, or for lengths of time that would take me away from my family for too long. Primary care positions would like me to be around Monday through Friday, with the occasional call weekend in some cases, for 3 months. This could work if they are within a reasonable traveling distance of my home and family, which does cut down on my options. Hospitalist positions, where I would take care of just patients in hospital, usually for 12 hours each day, are considered full time if I work 1 week on and one week off. If they are willing to fly me in and out, and the location is within a reasonable distance of an airport, that could work anywhere in the country. I would not have to be away for so long that my dog forgets who I am. Of all the jobs I could get, I would prefer "traditional internal medicine" which involves both outpatient and inpatient work because I think it will teach me more about a whole community and how it is coordinated to do health care. It is good locum tenens etiquette to apply for only one position at a time, which can lead to serial disappointments and presently I remain on the edge of my seat as I wait for confirmation of my first assignment. I'm sure it will be just fine and dandy, whatever it is, but it would be so reassuring to know where I will be in 2 months.
My resources for this adventure (my 2 years off from my regular primary practice) include quite a few friends and colleagues who have done or are still doing locum tenens (latin for "place holder") work. They tell me what places they have liked, where the ethics or the support might be thin, which companies take care of their clients. Sometimes they even know of specific needs, where I might work without using a recruiter at all. One such opportunity is doing telemedicine. Telemedicine is the practice of taking care of patients remotely, using telephone or computer. It is often practiced in places where the right doctor cannot be present physically, such as when a rare specialist is needed in a tiny hospital. It is used to share expertise over great distances, and is used internationally by some medical aid organizations. At the recommendation of a friend, I contacted an organization called MDLivecare, which provides telehealth services domestically, with private clients (people who arrange e-visits on their own) and corporate subscribers. A large company may wish to provide their employees with a way to contact a physician quickly, easily and inexpensively as a way to reduce time lost from work and in order to provide services more inexpensively. The telehealth visits include many of the trimmings of a real doctor visit, including documentation of what was discussed, communication with the primary care physician if there is one, and even prescription of medications (though controlled substances are strictly out.)
At some point in the future I will probably know more about telemedicine because I will probably try doing it. I have always enjoyed the challenge of treating patients over the phone, and having a video chat interface will be even easier than that. Much can be communicated verbally, and though loss of the touch aspect of medicine is a considerable hindrance to some diagnoses, I think it will be really interesting to see how much can be done in this type of an encounter.
Yesterday I visited with a patient who had a very odd neurological problem, a "funny walk" that was new and didn't really fit into patterns I had seen before. More than anything, I wanted her to be able to see a world class neurologist, who could probably ask a couple of questions, watch her walk down the hall and know what she had. But we were in a small town in a small state, and getting to a world class neurologist is probably nearly beyond her. It would be so simple, if telemedicine were more widely accepted, to call my favorite world class neurologist, web cam her funny walk, tell him my concerns and ask any questions he might have and get our answer. What presently hinders this are the fact that even practicing telemedicine requires a state license, and that there are no easy ways to bill for this service. Clearly that needs to change. We have technology at our fingertips that would reduce human suffering and we are hamstrung in our ability to use it. I look forward to the inevitable adjustments in payment schemes and regulations that will allow us to use what we have to its best advantage.
Wednesday, October 5, 2011
Meaningful use: the top heavy nit picky route to possibly better health care
As part of the 2009 American Recovery and Reinvestment act (the massive stimulus package enacted at the beginning of our economic slump) doctors were offered money to start using computerized medical records for their patients insured by Medicare and Medicaid. It was felt to be evident at that time that use of a computers to document patients' medical encounters would make communication between providers better, reduce errors, reduce redundancy of testing and procedures and overall streamline documentation. Many physicians had already started on the road to making their records digital, but government support made others take the big step. Our office bought a very expensive computer software package from GE along with all of the hardware to support it in 2007, and by the time the stimulus package passed, we had almost adjusted to the change. We figured we would probably be well set up to be rewarded for having made this momentous change before the majority of offices.
Adjusting to an electronic health record (EHR) is not easy. The programs for keeping such records are extremely complex, owing to the demands of privacy, legal issues, communication with other entities, drug prescribing, and the fact that most of these programs have been written over many years by programmers who no longer work for the same company and are no longer around to explain the rationale of the code they wrote, much less to fix it. The resulting products do really weird things and don't do some of the normal things that one would expect them to do. They don't automatically check spelling, for instance. They do lag, significantly. Perfectly simple tasks make them crash, and though these bugs are fixed, they reappear whenever there is an update. Of course, my experience is with GE's product, in our office, and doesn't necessarily apply to all EHRs, but from what I hear, many of them are plagued with the same problems.
In our office in the weeks following changing from dictating or writing our notes and communicating our plans orally or in handwritten notes to doing about all of this with a computer interface, our productivity dropped precipitously. If we could see half the number of patients we had seen prior to EHR it was a good day. People, including physicians, cried, yelled, quit their jobs. It was kind of awful. We had sick people to treat, and we couldn't access their histories, write their prescriptions, and we would sit with them, powerless in front of a computer screen that would not navigate to what we needed. After a couple of years we had almost become as fast as we were before computers, but truly we have never entirely recovered. Some things are definitely better. Our notes are readable. We know what we have prescribed and when. We are reminded of schedules for vaccinations and that sort of thing. We can produce a nice looking typed note for work in a couple of minutes. But we still spend lots of time staring at a screen rather than focusing on a patient and I, personally, am still slower, even though I am quite comfortable with computers.
It was a disappointment when we learned, about a year ago, that our computer system did not qualify us for any sort of reward through the Recovery and Reinvestment Act. What was required was "meaningful use" of an electronic health record. How, we wondered, were we to make it meaningful? It sure felt meaningful to us. The cost of it was pretty meaningful: over $100,000 for the initial investment, plus more than that much in updates and lost productivity. For a bunch more money, we found out, we could have "meaningful use" and be eligible for some payments. We have embarked on that road, and a rocky one it is.
Meaningful use requires 15 "core measures" be met along with 5 out of 10 menu items. We don't have do do every one with every patient, at least not yet, but we need to make a good start. The 15 core measures are:
1. We need to enter our orders (for things like tests and consults) on the computer.
2. We need to have the drug ordering part of the program be set up to tell us about drug interactions.
3. We need to keep an updated computerized problem list for each patient.
4. We have to transmit our prescriptions electronically, those that legally can be sent that way.
5 and 6. We have to keep active medication and allergy lists.
7. We have to keep demographic information of everybody, stuff like age, sex, language and ethnicity.
8. We have to keep record of all vital signs, including the body mass index and be able to graph growth in children.
9. We need to document whether the patient smokes (age 13 and older.)
10. We need to be able to transmit clinical quality data to Medicare.
11. We need to have our EHR help us make clinical decisions about at least one condition.
12. We need to supply patients with a summary of their health record on demand, including diagnoses, allergies, medications.
13. Within 3 days of a visit, the patient needs to receive a summary of their visit, including their problems
medication changes, what referrals were made and to whom, with contact information and what followup was recommended
14. We need to be able to transmit medical records to other providers electronically.
15. Our records must be secure.
The 10 menu items, from which we can choose 5, require that we:
1. Check insurance formularies so that patients know if the prescribed drug is covered and what other options are available.
2. Have lab tests be entered in such a way that the EHR can search them and use that data in various ways (i.e. not a scanned image.)
3. Generate lists of patients with specific condition.
4. Send patients reminders for followup for certain conditions and for prevention.
5. Provide patients with electronic access to their health information within 4 days of results being available.
6. Provide patient specific education resources (I think this means things like handouts on specific diseases.)
7. Do "medication reconciliation" -- making sure that medication lists from each provider are the same.
8. Provide summaries of care when a patient is transferred from one doctor to another.
9. Electronically submit vaccination data to agencies that collect that data.
10. Submit data on diseases or syndromes observed to appropriate agencies (like Dept of Health for infectious disease outbreaks.)
Most of these requirements are both reasonable and a good idea. Some of them are a really great idea, but figuring out how to do them is going to be a bear. The main one that has me worried is the summary of the patient visit. I used to write summary letters to patients after their yearly physicals. It took forever. Not only did I need to document the visit for my chart, I had to rewrite it in a way that a patient would understand. It just about doubled the amount of time it took to document a visit. It was also a great gesture, and I'm sure the patients usually benefited from it and appreciated it. I won't deny it is a good idea, but with the slowness of computer documentation as it is now, I wonder where we will find the time. I'm pretty sure that even a good computer can't take the data from a doctor's visit and turn it into prose that will be comprehensible to a real person, so to the extent that these documents are really useful, they will have to be generated by the doctor. We are expecting a bunch of new patients to be needing primary care doctors in the next several years, associated with a shortage of these providers, which will make it nearly impossible to spend more time in documentation.
Another thing that worries me is the requirement to submit data on quality to Medicare. Some measures health care quality are deeply meaningful, for instance, is the patient happier and healthier due to a medical encounter? Unfortunately, those outcomes are difficult to measure. Instead we measure whether diabetic patients have their blood sugars below a certain, somewhat arbitrary number, or whether women over a certain age have gotten mammograms. Many of the things that we decide are good and important in health care turn out to be not good when the next study comes out. For instance, we found that vitamin E wasn't good for anything, then found that it effectively treats fatty liver in obese patients. We still disagree about how often to get mammograms on patients, and screening for prostate cancer is a hotly disputed topic.
The updates to make our computer systems jump through these hoops will make us tear out our hair, once again, and stare helplessly at poorly functioning screens while sick patient wait for our help. I still hope that one day the intelligent and computer savvy generation behind me will be hired by Medicare to produce an EHR that is as lithe, supple and fast as a cheetah and we will all use that wonderful product which will be affordable due to economies of scale. I'm waiting eagerly. If that cheetah-like EHR comes to exist, it may well improve efficiency, reduce error and lead to better communication.
So how much money is offered to physicians who choose to attempt meaningful use? If we achieve this in 2011, we get $18,000 each. In 2012 we would get 12K, in 2013, 8K, 2015 4K and then in 2015, if we haven't achieved it, we will be penalized 1% of our medicare payment, then 2% the following year. If it takes until 2012, we only get 3 years of bonus, and so on. At most we can make $44,000 from meaningful use. That is a lot of money. It is also a drop in the bucket compared to what we will have spent in computer software, hardware and lost productivity. But that cat is out of the bag, and $44,000 is still a lot of money. The present meaningful use criteria will be replaced by stricter criteria, and it is not at all clear what those will be.
I'm not entirely sure what to think of this whole process. It seems that we are scurrying in vaguely the right direction, with better patient care as a goal, and an electronic health record as a tool to reach that goal. The way we are going about it, however, seems haphazard and destabilizing. Our aversion to truly standardizing our concepts of quality and our medical records is making these transitions much more difficult that they need to be.
Adjusting to an electronic health record (EHR) is not easy. The programs for keeping such records are extremely complex, owing to the demands of privacy, legal issues, communication with other entities, drug prescribing, and the fact that most of these programs have been written over many years by programmers who no longer work for the same company and are no longer around to explain the rationale of the code they wrote, much less to fix it. The resulting products do really weird things and don't do some of the normal things that one would expect them to do. They don't automatically check spelling, for instance. They do lag, significantly. Perfectly simple tasks make them crash, and though these bugs are fixed, they reappear whenever there is an update. Of course, my experience is with GE's product, in our office, and doesn't necessarily apply to all EHRs, but from what I hear, many of them are plagued with the same problems.
In our office in the weeks following changing from dictating or writing our notes and communicating our plans orally or in handwritten notes to doing about all of this with a computer interface, our productivity dropped precipitously. If we could see half the number of patients we had seen prior to EHR it was a good day. People, including physicians, cried, yelled, quit their jobs. It was kind of awful. We had sick people to treat, and we couldn't access their histories, write their prescriptions, and we would sit with them, powerless in front of a computer screen that would not navigate to what we needed. After a couple of years we had almost become as fast as we were before computers, but truly we have never entirely recovered. Some things are definitely better. Our notes are readable. We know what we have prescribed and when. We are reminded of schedules for vaccinations and that sort of thing. We can produce a nice looking typed note for work in a couple of minutes. But we still spend lots of time staring at a screen rather than focusing on a patient and I, personally, am still slower, even though I am quite comfortable with computers.
It was a disappointment when we learned, about a year ago, that our computer system did not qualify us for any sort of reward through the Recovery and Reinvestment Act. What was required was "meaningful use" of an electronic health record. How, we wondered, were we to make it meaningful? It sure felt meaningful to us. The cost of it was pretty meaningful: over $100,000 for the initial investment, plus more than that much in updates and lost productivity. For a bunch more money, we found out, we could have "meaningful use" and be eligible for some payments. We have embarked on that road, and a rocky one it is.
Meaningful use requires 15 "core measures" be met along with 5 out of 10 menu items. We don't have do do every one with every patient, at least not yet, but we need to make a good start. The 15 core measures are:
1. We need to enter our orders (for things like tests and consults) on the computer.
2. We need to have the drug ordering part of the program be set up to tell us about drug interactions.
3. We need to keep an updated computerized problem list for each patient.
4. We have to transmit our prescriptions electronically, those that legally can be sent that way.
5 and 6. We have to keep active medication and allergy lists.
7. We have to keep demographic information of everybody, stuff like age, sex, language and ethnicity.
8. We have to keep record of all vital signs, including the body mass index and be able to graph growth in children.
9. We need to document whether the patient smokes (age 13 and older.)
10. We need to be able to transmit clinical quality data to Medicare.
11. We need to have our EHR help us make clinical decisions about at least one condition.
12. We need to supply patients with a summary of their health record on demand, including diagnoses, allergies, medications.
13. Within 3 days of a visit, the patient needs to receive a summary of their visit, including their problems
medication changes, what referrals were made and to whom, with contact information and what followup was recommended
14. We need to be able to transmit medical records to other providers electronically.
15. Our records must be secure.
The 10 menu items, from which we can choose 5, require that we:
1. Check insurance formularies so that patients know if the prescribed drug is covered and what other options are available.
2. Have lab tests be entered in such a way that the EHR can search them and use that data in various ways (i.e. not a scanned image.)
3. Generate lists of patients with specific condition.
4. Send patients reminders for followup for certain conditions and for prevention.
5. Provide patients with electronic access to their health information within 4 days of results being available.
6. Provide patient specific education resources (I think this means things like handouts on specific diseases.)
7. Do "medication reconciliation" -- making sure that medication lists from each provider are the same.
8. Provide summaries of care when a patient is transferred from one doctor to another.
9. Electronically submit vaccination data to agencies that collect that data.
10. Submit data on diseases or syndromes observed to appropriate agencies (like Dept of Health for infectious disease outbreaks.)
Most of these requirements are both reasonable and a good idea. Some of them are a really great idea, but figuring out how to do them is going to be a bear. The main one that has me worried is the summary of the patient visit. I used to write summary letters to patients after their yearly physicals. It took forever. Not only did I need to document the visit for my chart, I had to rewrite it in a way that a patient would understand. It just about doubled the amount of time it took to document a visit. It was also a great gesture, and I'm sure the patients usually benefited from it and appreciated it. I won't deny it is a good idea, but with the slowness of computer documentation as it is now, I wonder where we will find the time. I'm pretty sure that even a good computer can't take the data from a doctor's visit and turn it into prose that will be comprehensible to a real person, so to the extent that these documents are really useful, they will have to be generated by the doctor. We are expecting a bunch of new patients to be needing primary care doctors in the next several years, associated with a shortage of these providers, which will make it nearly impossible to spend more time in documentation.
Another thing that worries me is the requirement to submit data on quality to Medicare. Some measures health care quality are deeply meaningful, for instance, is the patient happier and healthier due to a medical encounter? Unfortunately, those outcomes are difficult to measure. Instead we measure whether diabetic patients have their blood sugars below a certain, somewhat arbitrary number, or whether women over a certain age have gotten mammograms. Many of the things that we decide are good and important in health care turn out to be not good when the next study comes out. For instance, we found that vitamin E wasn't good for anything, then found that it effectively treats fatty liver in obese patients. We still disagree about how often to get mammograms on patients, and screening for prostate cancer is a hotly disputed topic.
The updates to make our computer systems jump through these hoops will make us tear out our hair, once again, and stare helplessly at poorly functioning screens while sick patient wait for our help. I still hope that one day the intelligent and computer savvy generation behind me will be hired by Medicare to produce an EHR that is as lithe, supple and fast as a cheetah and we will all use that wonderful product which will be affordable due to economies of scale. I'm waiting eagerly. If that cheetah-like EHR comes to exist, it may well improve efficiency, reduce error and lead to better communication.
So how much money is offered to physicians who choose to attempt meaningful use? If we achieve this in 2011, we get $18,000 each. In 2012 we would get 12K, in 2013, 8K, 2015 4K and then in 2015, if we haven't achieved it, we will be penalized 1% of our medicare payment, then 2% the following year. If it takes until 2012, we only get 3 years of bonus, and so on. At most we can make $44,000 from meaningful use. That is a lot of money. It is also a drop in the bucket compared to what we will have spent in computer software, hardware and lost productivity. But that cat is out of the bag, and $44,000 is still a lot of money. The present meaningful use criteria will be replaced by stricter criteria, and it is not at all clear what those will be.
I'm not entirely sure what to think of this whole process. It seems that we are scurrying in vaguely the right direction, with better patient care as a goal, and an electronic health record as a tool to reach that goal. The way we are going about it, however, seems haphazard and destabilizing. Our aversion to truly standardizing our concepts of quality and our medical records is making these transitions much more difficult that they need to be.
Wednesday, September 28, 2011
Patient Centered Outcomes Research--a good start
The affordable care act, in its 2000 plus pages, provided for many projects with the potential to improve health care delivery in the US. The most actively debated part of the bill, the mandate to insure just about everyone, may not turn out to be the most important piece. The problems the affordable care act attempted to address are the fact that American health care spending is too high and buys too little, including poor outcomes for those who do get health care and the fact that too few people who need health care actually receive it. All of these issues are addressed in some way or another in the myriad provisions of the bill.
One rarely advertised provision of the bill is the Patient Centered Outcomes Research Institute (PCORI). This is a private institute, publicly funded, which includes a huge diversity of players, from patients to providers and sundry others, who are charged with figuring out exactly what Patient Centered Outcomes Research is, and then making it happen and disseminating the results. According to a recent article in the New England Journal of Medicine, they have been holding meetings, many of them public, just to figure out what it is that they feel they should do and how they will most effectively do that thing. At this point the groundwork is mostly done.
The PCORI has decided that its prime directive is to help patients answer these 4 questions:
One rarely advertised provision of the bill is the Patient Centered Outcomes Research Institute (PCORI). This is a private institute, publicly funded, which includes a huge diversity of players, from patients to providers and sundry others, who are charged with figuring out exactly what Patient Centered Outcomes Research is, and then making it happen and disseminating the results. According to a recent article in the New England Journal of Medicine, they have been holding meetings, many of them public, just to figure out what it is that they feel they should do and how they will most effectively do that thing. At this point the groundwork is mostly done.
The PCORI has decided that its prime directive is to help patients answer these 4 questions:
- “Given my personal characteristics, conditions and preferences, what should I expect will happen to me?”
- “What are my options and what are the benefits and harms of those options?”
- “What can I do to improve the outcomes that are most important to me?”
- “How can the health care system improve my chances of achieving the outcomes I prefer?
Given the present scurrying behavior of most physicians to try to develop systems to help them practice evidence based medicine which will theoretically pay them more for reaching certain benchmarks in treating various common diseases, these patient centered questions are very relevant and an absolute necessity. As we as physicians begin to see our paychecks depend upon whether our diabetic patients are getting statin medications to prevent heart attacks and maintaining certain blood glucose levels, we vitally need to be reminded that our job is truly to improve patients' lives. That means adjusting what we do to respond to those patients' educated preferences. Results of patient centered outcomes research may help us do that.
I have some misgivings about the PCORI. It is very large. I can't quite figure out how large, but large enough that it sounds as if decision making is slow going. That will not slow the research that they fund, since that can be done by small groups with good ideas. Still, implementing change based on new research may be slow. I also wonder how information that helps doctors and patients make individualized decisions about care will interact with the freight train of "pay for performance" based on scientific evidence which usually demands strict adherence to a protocol.
I presently choose to have faith that the process of patient centered outcomes research will eventually meet up with pay for performance and we will actually be paid for the performance of individualized care for patients who are undeniably individuals with individual needs and preferences. It is just possible that the truth shall set us free.
Saturday, September 24, 2011
Physician non-compete clauses--another way to gut rural health care
Lately I have been dealing with the painful process of separating from my medical group. I have been part of this group since its inception, about 12 years ago. It serves two small towns in adjacent states and has about 30 employees and 12 providers, mostly located in the larger of our two clinics, in which I do not work. We originally came together from 3 primary care practices in order to share resources and reduce overhead. Cultures and values were somewhat different, but we did all care about delivering good quality medicine, letting our physicians have autonomy in decision making, and about making sure that each one of us could have lives that were humane, valuing family time or outside interests and covering each others' patient's needs so that care would not suffer.
When we came together we wrote a contract which was longer and more formal than any I had signed before and had various elements that made me somewhat uncomfortable. One was the "buy-in". This was an amount of money that we all agreed to put in to essentially buy the practice. I balked at the size of this, since my location of practice was very inexpensive, and the physicians in the larger office were "buying in" to a large and brand new medical office building. My concerns were respected, and my buy-in was smaller, as was that of my two partners. The other issue was a non-compete clause, which I was told was standard and non-negotiable. This clause in the contract stated that if my employment with the corporation ended, I would not practice medicine within 20 miles for 2 years.
Physician non-compete clauses are strongly disfavored by the American Medical Association and considered unethical. They restrict choice of practice and they penalize patients when a physician is at odds with his or her employer. They are hard to enforce and void in some states, most prominently California. They have been viewed as restrictions on trade, though various interpretations of this have arisen from court cases. They remain a common component of physician contracts. They are particularly hard to enforce if it can be shown that the physician is needed in his or her community and that enforcement of the clause will harm patients.
In the case of me and my clinic partner, who are obliged to sever our connection to our parent organization because our clinic is no longer viable after loss of half of our provider staff, there are a multitude of reasons why a non-compete clause is going to be unenforceable. The most important of these involves the patients in the community. Our town of just over 20,000 people now will have 2 rather than 4 internal medicine physicians, which is inadequate for our aging population. In another practice in town which has an even more restrictive non-compete clause, physicians are unable to make changes that might be in everyone's best interest, since if they leave the practice they must also leave the community and most of them are strongly tied to it, with children in school and spouses with jobs.
If a non-compete clause is unenforceable, unethical and disfavored by our national organization, why do we even worry about it? It is very common for an organization to threaten to enforce a non-compete clause, and to have this happen would be painful or disastrous. Court cases such as these cost 10s of thousands of dollars to complete and result in frequent and unpredictable time commitments that make it difficult or impossible to concentrate on a medical practice.
I have chosen to do a 2 year sabbatical at the end of my association with my present group for many reasons, and mostly because I really want to and think that the experience and knowledge I will pick up will be positively transforming in ways that I can't predict. But I would like to be able to fill in here or there in my community if I am needed during those two years. I can do the exile thing, but it is hardly good for my patients or colleagues, including those at the corporation I am leaving. Nevertheless, sabers are rattling and threats being spoken. My colleague is experiencing the same constraints. It affects both the community and our families, who will be mightily disrupted by our departure or frequent absences.
I have learned an important lesson, which I will not have trouble remembering. I will NEVER sign another contract which contains a non-compete clause.
http://www.wahcnews.com/newsletters/wa-jshore1210.pdf provides a lawyerly review of some of the issues.
http://www.gklaw.com/news.cfm?action=pub_detail&publication_id=842 presents a bit more on the AMAs position.
http://www.doctoremploymentlawyer.com/2011/08/physician-non-competes-being-e.html recognizes the power of the threat of enforcement.
When we came together we wrote a contract which was longer and more formal than any I had signed before and had various elements that made me somewhat uncomfortable. One was the "buy-in". This was an amount of money that we all agreed to put in to essentially buy the practice. I balked at the size of this, since my location of practice was very inexpensive, and the physicians in the larger office were "buying in" to a large and brand new medical office building. My concerns were respected, and my buy-in was smaller, as was that of my two partners. The other issue was a non-compete clause, which I was told was standard and non-negotiable. This clause in the contract stated that if my employment with the corporation ended, I would not practice medicine within 20 miles for 2 years.
Physician non-compete clauses are strongly disfavored by the American Medical Association and considered unethical. They restrict choice of practice and they penalize patients when a physician is at odds with his or her employer. They are hard to enforce and void in some states, most prominently California. They have been viewed as restrictions on trade, though various interpretations of this have arisen from court cases. They remain a common component of physician contracts. They are particularly hard to enforce if it can be shown that the physician is needed in his or her community and that enforcement of the clause will harm patients.
In the case of me and my clinic partner, who are obliged to sever our connection to our parent organization because our clinic is no longer viable after loss of half of our provider staff, there are a multitude of reasons why a non-compete clause is going to be unenforceable. The most important of these involves the patients in the community. Our town of just over 20,000 people now will have 2 rather than 4 internal medicine physicians, which is inadequate for our aging population. In another practice in town which has an even more restrictive non-compete clause, physicians are unable to make changes that might be in everyone's best interest, since if they leave the practice they must also leave the community and most of them are strongly tied to it, with children in school and spouses with jobs.
If a non-compete clause is unenforceable, unethical and disfavored by our national organization, why do we even worry about it? It is very common for an organization to threaten to enforce a non-compete clause, and to have this happen would be painful or disastrous. Court cases such as these cost 10s of thousands of dollars to complete and result in frequent and unpredictable time commitments that make it difficult or impossible to concentrate on a medical practice.
I have chosen to do a 2 year sabbatical at the end of my association with my present group for many reasons, and mostly because I really want to and think that the experience and knowledge I will pick up will be positively transforming in ways that I can't predict. But I would like to be able to fill in here or there in my community if I am needed during those two years. I can do the exile thing, but it is hardly good for my patients or colleagues, including those at the corporation I am leaving. Nevertheless, sabers are rattling and threats being spoken. My colleague is experiencing the same constraints. It affects both the community and our families, who will be mightily disrupted by our departure or frequent absences.
I have learned an important lesson, which I will not have trouble remembering. I will NEVER sign another contract which contains a non-compete clause.
http://www.wahcnews.com/newsletters/wa-jshore1210.pdf provides a lawyerly review of some of the issues.
http://www.gklaw.com/news.cfm?action=pub_detail&publication_id=842 presents a bit more on the AMAs position.
http://www.doctoremploymentlawyer.com/2011/08/physician-non-competes-being-e.html recognizes the power of the threat of enforcement.
Wednesday, September 21, 2011
Who wants me?
Today was filled with the usual stuff, which is actually never the same from day to day. My first patient of the day dropped in because she was having a stroke. She was actually my partner's patient, but I knew her pretty well from a previous visit and was happy to be able to help her out. I was also wickedly late for my first scheduled patient who just needed a preventive physical exam. Both were good interactions, understanding people with commendable patience (especially the one who waited an hour) and despite being clearly way behind for the rest of the day, it was what I love to do.
I have been more late, of late, because all of my routine appointments involve an explanation of what I'm doing when I quit my job next month, a recommendation for what to do for any health care needs, including a pretty exhaustive review of all of the doctors in the community who might be appropriate matches and some kind of heartfelt recognition of the length and depth of our doctor-patient relationship. This takes awhile, but is necessary and valuable. I have taken care of some of my patients for 17 years, and that means lots of stories told and heard, trust won and compromises hammered out. These are mini-divorces. They are not acrimonious, but they are intense. And then, of course, there is also the problem that the patient is having at the moment to be heard and maybe solved. My agenda at these appointments also involves looking at the whole set of problems and trying to make sure that we both have a clear view of the best strategies for getting them solved and that any loose ends are tied up.
The number of patient for whom a physician is responsible is difficult to glean from our medical records, due to the fact that many patients see a doctor only rarely, or see different doctors based on availability. But based on my official patient panel size when I worked for Group Health, and based on information from an internal medicine preceptor of mine many years ago, a full time physician might have 1800-3000 patients who regard them as "my doctor." The doctor patient relationship is important to most of these patients, even if they are seen infrequently, I am finding out. Some of the people who are most unhappy to see me go are people I see at most once a year. They don't come in with every ailment, but the fact that I exist and know them is really important to their feeling safe. At least that's what it sounds like.
But I'm not just doing this important doctor patient stuff, I'm also trying to find a job.
A primary care internist who is well educated, board certified, speaks English and hasn't done anything reprehensible is in demand in the US. I will find a job. The easiest of jobs to find will be in places that are very hard to get to, in rural areas where there are desperate doctor shortages.
When I first decided to contact a locum tenens recruiter, I went to the organization which had an excellent reputation with a locum tenens surgeon who I respected. I called them and was immediately put in contact with a man who told me a little bit about the whole process. He told me which states really needed physicians, what different jobs paid, that sort of thing, and tactfully tried to ascertain what awful skeleton in my closet was leading me to look for work. I told him my story of planned adventure, and he told me that anything was possible. He failed to outright relieve me of my misapprehensions about how I could get a really short term job anywhere I wanted whenever I wanted and be home with my family lots. He did that acquiescent groveling thing that representatives of drug companies do when they try to get me to use medications of dubious utility and ridiculously high cost. I tried to be reassuring so he would treat me like a regular person and give me straight advice, but it took over a month for me to realize that unless I wanted to go somewhere and work really hard for 3 or more months straight and then consider moving there, I was going to be looking at 12 hour hospital shifts or really remote locations with really not enough doctors to handle the patient volumes.
Just two days ago I finally decided I needed to contact a larger company with more job opportunities. I was immediately put in contact with two people who seemed more than capable of making me understand how the process works. There were several jobs that sounded possible, if not perfect. And today, through the first guy, I got a call from a very jolly, clearly English as a second language family practitioner from a microscopic town in Wisconsin not far from the Canadian border, and frankly it sounds pretty sweet. We shall see what comes of all of this.
I have been more late, of late, because all of my routine appointments involve an explanation of what I'm doing when I quit my job next month, a recommendation for what to do for any health care needs, including a pretty exhaustive review of all of the doctors in the community who might be appropriate matches and some kind of heartfelt recognition of the length and depth of our doctor-patient relationship. This takes awhile, but is necessary and valuable. I have taken care of some of my patients for 17 years, and that means lots of stories told and heard, trust won and compromises hammered out. These are mini-divorces. They are not acrimonious, but they are intense. And then, of course, there is also the problem that the patient is having at the moment to be heard and maybe solved. My agenda at these appointments also involves looking at the whole set of problems and trying to make sure that we both have a clear view of the best strategies for getting them solved and that any loose ends are tied up.
The number of patient for whom a physician is responsible is difficult to glean from our medical records, due to the fact that many patients see a doctor only rarely, or see different doctors based on availability. But based on my official patient panel size when I worked for Group Health, and based on information from an internal medicine preceptor of mine many years ago, a full time physician might have 1800-3000 patients who regard them as "my doctor." The doctor patient relationship is important to most of these patients, even if they are seen infrequently, I am finding out. Some of the people who are most unhappy to see me go are people I see at most once a year. They don't come in with every ailment, but the fact that I exist and know them is really important to their feeling safe. At least that's what it sounds like.
But I'm not just doing this important doctor patient stuff, I'm also trying to find a job.
A primary care internist who is well educated, board certified, speaks English and hasn't done anything reprehensible is in demand in the US. I will find a job. The easiest of jobs to find will be in places that are very hard to get to, in rural areas where there are desperate doctor shortages.
When I first decided to contact a locum tenens recruiter, I went to the organization which had an excellent reputation with a locum tenens surgeon who I respected. I called them and was immediately put in contact with a man who told me a little bit about the whole process. He told me which states really needed physicians, what different jobs paid, that sort of thing, and tactfully tried to ascertain what awful skeleton in my closet was leading me to look for work. I told him my story of planned adventure, and he told me that anything was possible. He failed to outright relieve me of my misapprehensions about how I could get a really short term job anywhere I wanted whenever I wanted and be home with my family lots. He did that acquiescent groveling thing that representatives of drug companies do when they try to get me to use medications of dubious utility and ridiculously high cost. I tried to be reassuring so he would treat me like a regular person and give me straight advice, but it took over a month for me to realize that unless I wanted to go somewhere and work really hard for 3 or more months straight and then consider moving there, I was going to be looking at 12 hour hospital shifts or really remote locations with really not enough doctors to handle the patient volumes.
Just two days ago I finally decided I needed to contact a larger company with more job opportunities. I was immediately put in contact with two people who seemed more than capable of making me understand how the process works. There were several jobs that sounded possible, if not perfect. And today, through the first guy, I got a call from a very jolly, clearly English as a second language family practitioner from a microscopic town in Wisconsin not far from the Canadian border, and frankly it sounds pretty sweet. We shall see what comes of all of this.
Monday, September 19, 2011
Walk, sing, practice medicine
I have worked as a primary care internal medicine doctor in a small university town for the last 17 years and have loved it more each year. I like my office, I feel at home and appreciated at the hospital across the street where I care for patients I know and for some who I eventually get to know through doctoring them. I can do intensive care medicine, take care of patients with delicate social situations and pick up the medical pieces with patients who have surgeries or injuries. It is never dull and it only rarely makes me feel sad or frustrated. I know the nurses well, count on them and am almost never disappointed. My relationships with my fellow physicians are warm and I respect them.
On October 31 of this year I am quitting my job. I am not old, so I am not retiring. It's just time to do something else. Various things happened which were the universe's way of telling me that I needed to do something different. My nurse practitioner partner with whom I shared an office, a world view and plans for future brilliant schemes, died suddenly in April, and one of 3 remaining partners in my clinic decided to take a job elsewhere as a kind of partial retirement. It is not possible to effectively hire another internal medicine doctor for a clinic such as ours in a small town such as ours with any degree of certainty, and my remaining partner and I were becoming swamped. It is possible to keep up with the level of work we were doing for a few months, but not for the rest of my work life.
My plan is to get as many experiences as possible practicing medicine as many places and settings as I can for the next two years. I want to see how other people do what I do, how other systems work, how they don't work, what they smell like, feel like, taste like. I would also like to take long walks in places I've never been, and since I'm asking for what I want, sing. I love singing with people and it is a hobby that is not hard to indulge. I especially like singing with small groups in harmony. But more about that later, perhaps. I bet I'll be able to squeeze some good music into the next year or two. I will also take lots of delicious continuing medical education courses and learn from academics how to do things that I don't know how to do.
I'm calling it a sabbatical. The term "walkabout" would also be accurate. That term, as I understand it, refers to native Australian's need to leave what they are doing and do something else, somewhere else, for a time. It's a fascinating concept, but it is not entirely clear how it's going to work. I have started to look into my options by signing up with a locums company, a group that will find me jobs in places where they desperately need a doctor to fill in for a time. Ideally, these positions would be for just long enough for me to experience a new place and get familiar with their routines, meet new people, explore my new communities. I'm finding out, though, that jobs want me for as long as possible, as full time as possible, and preferably they would like me to eventually move there and take the job full time.
I would also like to go back to Haiti, to La Gonave, and work with the communities that I have started to get to know on public health issues such as birth control, safe sex, contraception and building healthcare teams. This is expensive for me, but will be less expensive when I am not having to pay a staff and an office to run in my absence.
I also plan to work in a rather remote clinic in Alaska where a friend of mine has worked for years, intermittently, but probably not starting in the dead of winter. I will work this out myself, with the help of the hospital administrator there.
Locum tenens companies, like the one I signed up with, take care of the details of credentialing, malpractice insurance, arranging licenses, travel, housing and any money negotiations that have to happen. They also charge a lot of money for doing this, which is absorbed by the poor desperate hospital or clinic that uses their services to fill a slot. This means that, by participating in this process I will be directly contributing to high health care costs. I do like the idea of having everything arranged, but in the best of all possible worlds, I will find at least some of my own jobs and negotiate the details myself.
Other than the fact that I am leaving my patients and community in a lurch, this is a great plan. I get the idea, though, that it won't go particularly smoothly. It seems entirely possible that I won't get exactly what I want, and sometimes not vaguely what I want. I am expecting that by the process of trying various things, failing and succeeding, I will learn lots of amazing stuff, including how to do this thing that I'm going to be doing. If I do figure that out, maybe it will make this kind of thing easier for other physicians to do. The reason that it is a great idea is that medical practices are kind of like little Galapagos islands, developing procedures, tricks, solutions that they never share with other groups. Deliberately learning new stuff and sharing it just has to be something that holds hope for improving medical care and efficiency.
I will be using this blog to document my adventures, should I have them, and the perils and pitfalls of getting this stuff all arranged. I will also continue to write about the wonderful tidbits of American medical care in its glory and absurdity as I have been doing.
On October 31 of this year I am quitting my job. I am not old, so I am not retiring. It's just time to do something else. Various things happened which were the universe's way of telling me that I needed to do something different. My nurse practitioner partner with whom I shared an office, a world view and plans for future brilliant schemes, died suddenly in April, and one of 3 remaining partners in my clinic decided to take a job elsewhere as a kind of partial retirement. It is not possible to effectively hire another internal medicine doctor for a clinic such as ours in a small town such as ours with any degree of certainty, and my remaining partner and I were becoming swamped. It is possible to keep up with the level of work we were doing for a few months, but not for the rest of my work life.
My plan is to get as many experiences as possible practicing medicine as many places and settings as I can for the next two years. I want to see how other people do what I do, how other systems work, how they don't work, what they smell like, feel like, taste like. I would also like to take long walks in places I've never been, and since I'm asking for what I want, sing. I love singing with people and it is a hobby that is not hard to indulge. I especially like singing with small groups in harmony. But more about that later, perhaps. I bet I'll be able to squeeze some good music into the next year or two. I will also take lots of delicious continuing medical education courses and learn from academics how to do things that I don't know how to do.
I'm calling it a sabbatical. The term "walkabout" would also be accurate. That term, as I understand it, refers to native Australian's need to leave what they are doing and do something else, somewhere else, for a time. It's a fascinating concept, but it is not entirely clear how it's going to work. I have started to look into my options by signing up with a locums company, a group that will find me jobs in places where they desperately need a doctor to fill in for a time. Ideally, these positions would be for just long enough for me to experience a new place and get familiar with their routines, meet new people, explore my new communities. I'm finding out, though, that jobs want me for as long as possible, as full time as possible, and preferably they would like me to eventually move there and take the job full time.
I would also like to go back to Haiti, to La Gonave, and work with the communities that I have started to get to know on public health issues such as birth control, safe sex, contraception and building healthcare teams. This is expensive for me, but will be less expensive when I am not having to pay a staff and an office to run in my absence.
I also plan to work in a rather remote clinic in Alaska where a friend of mine has worked for years, intermittently, but probably not starting in the dead of winter. I will work this out myself, with the help of the hospital administrator there.
Locum tenens companies, like the one I signed up with, take care of the details of credentialing, malpractice insurance, arranging licenses, travel, housing and any money negotiations that have to happen. They also charge a lot of money for doing this, which is absorbed by the poor desperate hospital or clinic that uses their services to fill a slot. This means that, by participating in this process I will be directly contributing to high health care costs. I do like the idea of having everything arranged, but in the best of all possible worlds, I will find at least some of my own jobs and negotiate the details myself.
Other than the fact that I am leaving my patients and community in a lurch, this is a great plan. I get the idea, though, that it won't go particularly smoothly. It seems entirely possible that I won't get exactly what I want, and sometimes not vaguely what I want. I am expecting that by the process of trying various things, failing and succeeding, I will learn lots of amazing stuff, including how to do this thing that I'm going to be doing. If I do figure that out, maybe it will make this kind of thing easier for other physicians to do. The reason that it is a great idea is that medical practices are kind of like little Galapagos islands, developing procedures, tricks, solutions that they never share with other groups. Deliberately learning new stuff and sharing it just has to be something that holds hope for improving medical care and efficiency.
I will be using this blog to document my adventures, should I have them, and the perils and pitfalls of getting this stuff all arranged. I will also continue to write about the wonderful tidbits of American medical care in its glory and absurdity as I have been doing.
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