How to Stop Incenting EMR Note Bloat

It happened again today: an elderly lady with critical aortic stenosis with all it's cool findings: late peaking harsh, palpable murmur, Gallavardin phenomenon, LV heave - the works! And what did the electronic medical record from the intern picking up the patient say?

"CV - Irreg rate and rhythm, no murmurs, clicks or rubs."

No doubt this was a documentation macro that was not edited or else the intern failed to examine the patient (or maybe both).

No excuse! It's time to end the crap being spewed forth into electronic medical records!

I say that every time such a note is discovered like this by our new medical trainess, they fail their rotation. Yep: make the penalty severe and make it stick! That way, they'll think HARD about what they contribute to the medical record and be held accountable!

Of course there's a few sticky problems with such a heavy-handed approach:

1. Attendings do not critically review what is actually written in the chart by interns because it is buried in pages of electronic morass and rarely found, and...
2. No one has a clue what to do to attendings who do the same thing. After all, when it comes to getting paid for your work, it's not about what doctors write in a chart, it's about how many things doctors write about so they can bill the government for their professional services.

-Wes

The Question

There they were, little maroon flags outside three patient exam room doors. You could almost hear the game show host ask the question:

Will it be Door #1, Door #2, or Door #3?"

So I asked the medical assistant, "Who's next?" and she pointed me to Door #2.

It was a new patient with a familiar problem, one I've seen probably a thousand times before. Another day, another case. Bada bing, bada boom. Nothing to it. You would think that all cases, and all people are the same in some ways. Certainly, those managing our health care system of the future would like us to believe it's so simple: just another case of heart failure (what can go wrong?) or supraventricular tachycardia (love that one, there's NOTHING hard about that!) or maybe a few PVC's (Check). Another day, another dollar.

I suppose it would be easy to classify patients that way, after all, I'm now just a "proceduralist for the heart electrical system" in the eyes of many these days. But there is something that I always find myself looking for with each new patient I see: The Question.

The Question is the query that irreversibly connects you with the patient. It's not the details of the history of present illness or the past medical or surgical history, rather, it's The Question that makes the patient look at you in a slightly different way. It's The Question that makes them realize you're human. It's The Question that let's them know you're interested. It's The Question that is outside the rubric of medical history taking. It's The Question that keeps you coming back for more, day in and day out.

The cool thing about The Question is it's usually different for every patient. In fact, it is invariably unique to a given patient. The challenge for every doctor is finding it. And the weird thing is, you might not know you found it at first. But when someone asks you about the patient, it's invariably The Question and its answer that you recall along side their health issue. It might be a simple, "What kind of work do (did) you do?" or "What's your son doing now?" or even "Nice shirt. Where did you get that?" Nothing complicated, mind you. You hear about the job, the kids, the passions: people being people, not just an algorithm.

And the best part?

There's always (and I mean always) something new to learn.

-Wes

On Closure

The chief complaint, the history and physical, the differential diagnosis, the proper testing, the treatment.

From Day 1, these are the pieces of medicine that are hammered in to young doctors' heads: the best way to treat this or that, the best drug, widget or gizmo, the latest advance. We learn which approach is better than the other, which treatment to apply when more conventional approaches can't be taken. Each of these steps are drilled over and over again in the hopes of crafting a strategy for each clinical scenario a doctor is likely to encounter. Yet while each of these steps that are learned are important in their own right, few of these steps are critical to doctors' sustainability in their profession.

Because after the treatment strategy or therapy is applied, there's another vital part of the medical care that is often under-appreciated for doctors and policy makers: the closure.

"Closure" is the time in medicine where we either revel in our success or squirm in our failure. It's where we must face the music - good or bad - with our patients. More often than not, it's the time for doctors that brings meaning to our efforts and the hours we work.

Closure can occur at different times for different doctors. For specialists (increasingly called "proceduralists" these days), closure usually occurs in the post-operative or post-procedure period. For primary care doctors, "closure" occurs during the follow-up visit after a prolonged hosptitalization or difficult illness. For both types of doctors, it's the chance to see the good they did or bad they did first-hand. It a time to validate their understanding of the patient's ailment and the caliber of their treatment plan. Importantly, it's not the end of the patient's ongoing care but rather, it's the conclusion to a particular chapter of their care. For doctors, it's the critical time we grow as professionals.

Yet sadly, these moments of closure are becoming rarer for both the patient and the doctor.

With doctors racing between facilities on productivity compensation plans who must perform more cases in less time and in more locations to offset declining payment rates, it's become harder both logistically and financially to justify excessive post-operative time with patients after their procedures. The money required to feed the our massive system of administrators, collectors, quality score counters, overheads and salaries demands a constant ever-growing source of funds, so doctors must keep moving.

To that end, specialist physicians have seen post-operative care routinely clumped together with the pre-procedure and intra-operative care as one big "encounter" that pays health systems only once. Increasingly to add "value" to health care dollars, policy makers are shifting the "risk" of caring for patients to the providers of that care. Insurers and policy makers like to call this shifting from "procedural-based" payments to "outcome-based" payments. In theory this sounds nice, but it's robbing the doctors of the closure time so critical in the valuation of their profession in favor of treating a greater quantity of healthier, lower-risk patients to assure reliable payments to the system.

For primary care doctors who now only see patients in their offices, the opporunity to see the product of a continuous care strategy has been surrendered to the hospitalist movement robbing them of closure time. And even the hospitalists who "diagnose and say 'adios'" from the confines of the hospital, the opportunity see the late consequences of their care in a non-critical environment has been lost to production quotas as well. No fractious group "medical home" care in the world can replace this loss of closure inflicted upon primary care and shift-working hospitalist physicians or the patients for whom they care.

Our health policy analysts have assured us these "closure" visits can be accomplished by ancillary care providers. Technically, they are correct. But there is no question that the loss of these post-procedure visits by the treating physician or operating surgeon robs them of a critically important opportunity for continuous self-improvement as they reflect on the quality and cailber of their work first-hand. Further, doctors lose an opportuntity after the haze of amnestic medications have subsided to educate and re-connect. Doctors need this time with their patients just like patients like this time with their doctors - maybe even more. It's what makes it worthwhile to get up and do it all again.

Despite the current push, I still try to see my patients after a procedure whenever possible. Sure, we don't get paid for this, but I still relish a patient's gentle smile or a quiet "thank you." More importantly, when things aren't perfect, I need the opportunity to reassure and console. If things really don't go well, I find there are huge benefits derived when I can explain and empathize with the patient's situation.

Still, I feel the tug. "It's not efficient," they tell me.

Perhaps.

But it's this closure that sustains me and I suspect sustains many in our profession. And honestly? If doctors' closure time continues to be parsed and devalued further, they'll look for validation of their work elsewhere.

Then what kind of closure will we have?

-Wes

The Lost Art of Auscultation

From the nice piece just published in the New York Times:

“He told us that one of the things that had surprised him most about being a patient was that every single person he interacted with — be they nurse, resident, senior physician, respiratory tech, physical therapist — it was as though they had a neon sign on their forehead that said either ‘I care’ or ‘I don’t care.’ ”

But what illuminates those neon signs? What are the clues that were so starkly apparent to me, even in second-year medical students?

Perhaps the answer lies in the medical lexicon. Auscultation — listening to heart sounds with a stethoscope — is a required skill.

Read the whole thing.

-Wes

A Stethoscope App for the iPhone

It's out there. It makes a cool picture, but I wonder how many medical students realize how unimportant apps like this have become to today's cardiovascular care. Don't get me wrong, it's good to hear the difference between a systolic and diastolic murmur, or for the really talented, a diastolic rumble on physical exam. Recognizing the difference between mild and severe aortic stenosis is also very helpful. After all, the physical exam remains the most cost-effective instrument in medicine.

But graphics to show the murmur that requires an electronic stethoscope and preamplifier to connect them to your iPhone? How much money do you want to waste on these toys?

The best way I know how to learn is get off the computer and get to the bedside. Look, listen, and feel the precordium a thousand times over. Only by doing will you learn. You really don't need an expensive stethoscope (but it does helps the auditorially challenged). I admit that I've stopped using super-expensive stethoscopes because I always lose them when I change into scrubs or round on too many different wards (or they're often stolen).

Honestly, by the time I'm asked to see a patient, the echocardiogram is already done, so for me, listening to the lung sounds and measuring blood pressures (especially orthostatics for patients with syncope) remains the most important reason I still carry (or borrow) an the old, cheesy, analog version of the stethoscope.

-Wes

h/t: Dr. Joseph Kim via Twitter.

The Careful Exam

When looking for the cause of atrial fibrillation during a physical examination, not only can the doctor's olfactory bulb be helpful, but so can the examination of what gets brought into the exam room.

Patient: "Hey doc, it's just a Pepsi."



Doctor: "Really? Can I see?"




Nothing a good knife and a piece of scotch tape can't manufacture.

Case solved.

-Wes

Health Care Cut Backs

... are affecting everyone:

"Doctors are noticing the trend as patients skip or defer treatments because of the troubled economy.

Many decline procedures even when they have medical insurance, doctors said, because the procedures are so expensive they can't afford the out-of-pocket costs. For a colonoscopy, a stress test, an MRI or a CT scan, the patient's co-pay can run to hundreds of dollars."

It was interesting to note that the article quoted a local "recently retired" internist. The untold story within this story is that hospital systems are equally strained as procedural revenues dwindle, placing increased pressure on their physician workforces to "produce."

-Wes

What Will They Think of Next?

Just when you think you've seen it all, along comes the Whizzinator.

Geez, that would make for one heck of a physical exam.

-Wes

Who Knew? History's Important

I am shocked, SHOCKED I tell you, to find that taking a history from a patient is important:

However, almost half of all coronary "events", such as heart attacks, that happened during this period, happened in patients whose ECG results had not shown any sign of problems.

A routine clinical assessment, which involved taking a detailed "history" from the patient, and examining them thoroughly, was almost as good in predicting future heart disease as the exercise ECG.

The researchers concluded that the tests were "of limited value" to doctors faced by patients with no prior heart disease.

Dr Mike Knapton, from the British Heart Foundation said that while early diagnosis of angina was important, the study showed that the best way to achieve that was to talk to the patient.

Who knew?

-Wes

Say It Ain't So

... the death of the stethoscope? Somehow placing recordings of heart and breath sounds from an MP3 player/recorder in the medical record seems a bit extreme, but hey, such a device could probably do it. The real question is, would anyone stop and listen? With ever-growing pressure to improve "productivity," I doubt it.

But the best part? I'd stop looking like a doctor and look like this guy.

I'm sure that look would engender total confidence in my clinical skills by my patients.

Then again, maybe not.

-Wes

Endangered Species

A Regular Sphygmomanometer (Blood Pressure Cuff)

Have you notice how manual blood pressure cuffs are becoming extinct on hospital wards? I'm adding them to my "endangered species" list. It seems fewer and fewer people use these on the inpatient wards anymore. Instead, hospitals seem to be gravitating toward wall-mounted or cart-mounted electronic versions that can take your temperature and pulse oximetry, too, like the one to the right.
These electronic versions do not require the use of - dare I say it - a stethoscope and ears. (I've already commented on the quality of stethoscopes has suffered with the advent of the little plastic stethoscopes, so with these new-fangled gizmos, we don't even need those!).

One reason hospital administrators have migrated away from these manual BP cuffs is because they have lots of complicated detachable parts - the rubber bulb cracks and loses air, the tubing similarly fractures, and the calibration of the BP meter itself was difficult to maintain from the heavy use these devices see. But the new devices have even more issues, it's just that now we have to call a specialist to fix them. But, hey, at least they look cool.

The mobility of these old-fashioned, untethered devices had several advantages over their technogeek counterparts: (1) they permitted measurement of blood pressures in different patient positions - supine, sitting, and standing (recall that we call these orthostatic blood pressures) - since they are less resistant to motion artifact and (2) the manual version can recognize a drop in blood pressure faster than you can say "Holy Sh**!" Many a poor patient has hit the deck while the techoversion keeps inflating the cuff higher and higher in its attempts to find a hypotensive patient's blood pressure.

Recently, I have been struck by the number of patients I have seen with loss of consciousness (syncope). Most are men over 70, and most of them on a ton of medications - and all episodes of syncope seem to generate a consultation for the cardiac electrophysiologist (my kids appreciate this - really they do).

But one of the more common drugs I see elderly men on are medications for prostatic hypertrophy - in particular, terazosin hydrochloride (Hytrin®) or tamsulosin hydrochloride (Flomax®). These medications are prescribed for benign prostatic hypertrophy (BPH) to improve urine flow, especially at night.

But they also can drop blood pressure.

And nothing will make you hit the deck faster that a full bladder, warm body (after being in bed), rapidly standing, and being on too much Hytrin - blammo - down like a ton of bricks. Quick, call the electrophysiologist for a pacemaker!

For some reason (and I suspect its the abandonment of the manual BP cuff), few people check orthostatic blood pressures anymore, and so a simple diagnosis (and treatment) is missed.

But then again, I guess I shouldn't complain.

-Wes

Imagine: Physical Exam Can Save Lives

Embarassingly, a study in the British Medical Journal Online First reveals a window into the "non-touch," paint-by-numbers world of health care today: it seems that if doctors actually checked a pulse, they might be able to reduce the risk of stroke by detecting atrial fibrillation.

Who knew?

What will our government-run health care systems think of next?

-Wes