Tuesday, October 14, 2008

Father Knows Best

Welcome to the next episode of Father Knows Best entitled, "Best Practice Alerts:"
Have a diabetic without a HbA1c?
* Ding Ding * You get a best practice alert!

Have a patient without an mammogram in the last year?
*Ding Ding* You get a best practice alert!

Haven't had your colostomy colonoscopy and over age 50?
*Ding Ding* You get a best practice alert!

Haven't counselled you patient about their smoking each year?
* Ding Ding * You get a best practice alert!

Haven't had your cholesterol checked?
* Ding Ding * You get a best practice alert!

Didn't screen your patient over 18 for depression?
* Ding Ding * You get a best practice alert!

Didn't know that there 134 potential alerts for 2008?
*Ding Ding * You clearly need a best practice alert!
"Best Practice Alerts" are computer algorithms triggered from diagnosis codes.

"Best Practice Alerts" are an Electronic Medical Record's (EMR) means to assure that the "voluntary" Physicians Quality Reporting Initiative is undertaken. Never mind that failing to comply means certain discrimination between physicians. Just remember, it's voluntary! Really.

"Best Practice Alerts" force doctors to cross tacit specialty treatment boundaries and risk alientating referral doctors.

"Best Practice Alerts" drive testing and procedures, and therefore costs, to our health care system.

"Best Practice Alerts" are encouraged by those with a stake in health care.

"Best Practice Alerts" remove judgement from medical care in favor of mandates.

"Best Practice Alerts" are disruptive to doctor-patient interactions, consuming precious clinic time as "why" or "why not" must accompany each alert response.

"Best Practice Alerts" have not been shown to improve patient outcomes over more conventional care.

So how, then, are we to assume such alerts represent "Best Practice?"

Well, it's simple: because Father knows best.


Image reference: TVGuide.com


rlbates said...

Love this post!

shadowfax said...

Wow, the practice requirements are a *lot* more stringent that I would have thought from my post in the ER. I didn't know they were recommending routine prophylactic colostomies for everyone over 50.

I'm not looking forward to that.

Anonymous said...

Wes, I think you mean "colonoscopy" not "colostomy"

p.s. how's your back doing?

DrWes said...


Heh. Shows you what us cardiologists know, eh? Thanks for the pickup. Had a, er, brain fart I guess. Correction made.

Back's doing MUCH better. Thanks for askin'.

Anonymous said...

I ask this in all sincerity, from a patient's perspective: what happens if the pt does not follow through on these things? I love my PCP more than words can say, and I don't want to get him in any trouble. That being said, for my own reasons, I will not submit to many of these tests/procedures. He knows this and, out of his concern for my wellbeing, is not happy about my "noncompliance" but he also knows that forcing the issue will result in my avoiding him for the issues I *DO* follow through on.

What happens to the doc in situations like that?

DrWes said...

Anony 4:03 PM -

Your doctor will not be "dinged" as long as he has documented that he attempted to perform the measures mandated by the PQRI initiative. He's done his part. But there are measures of effectiveness of therapy upon which he or she is measured, so if you were to choose not to manage your blood pressure or diabetes (just as an example), you might contribute to your doctor's diminished quality rating and payments from Medicare. From the CMS website:

"If there are no more than three quality measures applicable to the services provided by the Eligible Professional (EP), then each measure must be reported for at least 80% of the cases in which the measure was reportable. If there are four or more quality measures applicable to the services provided by the EP, then at least three measures, selected by the EP, must be reported for at least 80% of the cases in which each measure was reportable. EPs are encouraged to report on as many quality measures as are applicable to the services provided. Reporting on as many applicable measures as is practical will increase the opportunities to reach the 80% successful reporting level."

Doesn't that sound like fun? All of that for an additional $1.12 (1.5%) on a $75 dollar office visit.

Unknown said...

Dr. Fisher -

Here's the link to the blog I told you about: http://blogs.middlebury.edu/grilleghost/2008/10/01/401-keg-plans-prove-sound-investment-for-college-students/


Anonymous said...

Thank you for answering my question regarding patient "noncompliance." Perhaps I am coming late to this party/realization, but not only do these "best practice" issues sound like a royal pain for the doctors, there can well be ramifications for patients in many ways. For instance, if I were my doctor, I wouldn't want to treat me! Regardless of concerns for my health and wellbeing, patients like me can diminish your quality rating, just for exercising our right to refuse treatment. If I were a doctor, I would think twice (at least) about dropping such patients from my caseload.

My PCP is fabulous. I'd hate to see his quality ratings suffer because people like me make our choices, but I also see that these rating issues have the potential to bully me as the patient (not my doc doing the bullying, you understand).

Where will this end? Will my insurance company say "get a mammogram or get off our plan?" "take statins or else?"

This is scary stuff from the patient's perspective too. But I suspect you knew that already. Thanks for keeping us well informed on this craziness.

Dragonfly said...

This post is awesome.

Lisa G said...

Fabulous post. Given my field (skilled nursing), CMS drives me absolutely batshit. There are over 500 Federal regulations that I have to meet in order not to get a citation. When will it END??