When Physicians Drown in Noise

The infrequent side effects of Paxil
(Click to enlarge)

I was just trying to look up the side effects of Paxil and was greeted to this incredible and quite ridiculous array of potential side effects.

I had to ask myself: how helpful is such a list? Why do we have this noise available to us?

The answer, of course, is obvious to anyone who understands our legal system in America.

But we should ask ourselves another question: in our effort to assure patient safety, might we be losing important signals to care-givers amongst the recesses of all of this incredible noise?

-Wes

Liability Reform: It's Coming

A collision is coming.

Scratch that.

The collision is here.

I'm not quite sure how to describe this, but I'll try.

Every day, I look at a computer screen for health care delivery with an increasing number of menu options.  I tried counting these menu options once and after scrolling through them, I never reached all of them after counting up to 275 items.

Yes, there are more than that, but suffice it to say, for most of us, that's enough to make my point.

Next, are the data points that confront my eyes every day.  Data points from all over and from all sorts of people.  Some whose names I recognize (even a few from me), but more importantly, many of whom I don't.  Hundreds and hundreds and hundreds of data points, streaming to me every single day.

What are these interrupters?

Many are orders for procedures.

Others are for results.

And phone calls.

And messages.

And patients recently admitted to other services for other procedures just so I know about them.

And patients to be scheduled for a procedure at a later date.

And blood draws.

And EKGs that have been ordered and not "signed."

And EKGs that have been read and not "signed."

And EKG results that were "signed" but returned to my "results" box just to remind me I "signed" them.

And ... well, just about anything.

All as part of the Great Medical Health Care Team plan.

But wait, who ordered all of these procedures, tests, results to be sent my way?

Some I did, but far more often, other people did.

Those other people are people who have been ordained capable of ordering those tests by other people.  Other people in our big, burgeoning health care system that extends over a larger an larger geographic area with more and more doctors than ever before.

And herein lies the challenge and the best hope for doctors' liability reform going forward: diffusion of their responsibility.

A few central planners whose grandiose health care narcissism have allowed unfettered access to physician responsibility for health care actions outside our real control in our new health care model so they can be paid.  Perhaps this was inevitable given the priority of providing care of so many more people without increasing doctors' ranks.    But as a result, doctors have unwittingly permitted programmers to send us all of these "notifications" so we must click on them so we can assume responsibility for their presence.  It's all part of the game:  get the doctor to click on it so it can be billed to payers.   Get the doctor to click on it so he or she can take the heat if there's a problem.

Licensed medical doctors continue to allow click after click after click, not to show we are using a computer "meaningfully" (as the programmers and political wonks would like you to believe), but really so we can assume responsibility for the results that ultimately come our way and for others to bill.

Need a flu shot?  Don't worry, it's auto-programmed computerized care pathway programmed by others on behalf of patients everywhere will happily send us a notification that the test was ordered and the results sent to the doctor so he or she can assume responsibility before he or she is even aware the test was ordered and resulted.  There it is: silently lying there in their inbox.

Click, doctor, click.

Forget about the egg allergy?  Oops.

Sorry, doc.

But increasingly, there's a little something that's happening as patients assume more of their health care bill: doctors are finding that they are effectively "responsible," even though we have no idea what things cost.  We are "responsible" for the patient's tests ordered, even though we didn't order them.  We are responsible for the results, because they come our way.  We are responsible for our "team," even though we had no responsibility for its selection.

The fanciful dream that doctors can be responsible for problems that arise can be completely blamed on doctors is a joke.  A very, very bad joke.

This is why liability reform will happen, whether the lawyers like it or not....

... not because doctors want it (even though they do), but because Big Business does.

-Wes

When Patients Can Obtain Their Own EKG

With the announcement that the FDA granted 510(k) approval for the AliveCor EKG case for the iPhone 4/4s, the device became available to "licensed U.S. medical professionals and prescribed patients to record, display, store, and transfer single-channel electrocardiogram (ECG) rhythms."

While this sounds nice, how, exactly, does one become a "prescribed patient?"  Once a doctor "prescribes" such a device, what are his responsibilities?  Does this obligate the physician to 24/7/365 availability for EKG interpretations?  How are HIPAA-compliant tracings sent between doctor and patient?  How are the tracings and medical care documented in the (electronic) medical record?  What are the legal risks to the doctor if the patient transmits OTHER patient's EKG's to OTHER people, non-securely?

At this point, no one knows.  We are entering into new, uncharted medicolegal territory.

But the legal risks for prescribing a device to a patient are, sadly, probably real, especially since the FDA has now officially sanctioned this little iPhone case as a real, "live" medical device.  But I must say, I am not a legal expert in this area and would defer to others with more legal expertise to comment on these thorny issues.

This issue came up because a patient saw the device demonstrated in my office and wanted me to prescribe it for them.  So I sent AliveCor's Dr. Dave Alpert a tweet and later received this "how to" e-mail response from their support team:

Dear Dr. Fisher,


Thank you for your interest in the AliveCor Heart Monitor. I'm writing in response to your tweet to Dr. Dave (Alpert) yesterday. Below are the instructions; in addition these instructions can be found at www.alivecor.com (click on the “Buy Now” link in the upper right corner).

To obtain a monitor for your patients, please follow these steps:

1. Write a prescription for the “AliveCor Heart Monitor for iPhone 4/4S”

2. Ask your patient to go to here and submit the following:

a. The prescriber’s information - your name, address, phone number, license number and license state or NPI (National Provider Identifier)

b. A copy of the prescription (attach a scanned copy or photo)

3. Go to www.alivecor.com and click on the “Buy Now” link in the upper right to purchase the monitor

a. In the “NPI/State Medical Lic #” enter “Prescription”

NOTE: The patient's credit card will be charged once they place their order, however we can’t process their order unless we have received their prescription.

Please know that at this time AliveCor does not provide any ECG interpretation, diagnosis or analysis of the data obtained with the monitor. Patients will be instructed to contact you, their physician, regarding any questions they may have regarding their recordings.

Please let me know if you have any questions.

Regards,

It is clear AliveCor wants to provide the device and its app, but will not be responsible for the interpretation of EKG's.  That is up to the doctor and their patient how to manage the clinical expectations of this technology.  While some patients could probably perform EKG interpretation basics, I would guess most don't really understand what that wavy line means.  Hence, this is where a discussion should be held with a patient BEFORE prescribing this device and the expectations defined before its use.

For me, I am happy to provide interpretations free of charge when needed as long as it is convenient and non-disruptive to my clinical responsibilities and personal life.  There are only so many hours of the day and since I must value that time, cannot bill for this EKG-reading service, and have no quality control over the caliber of the recordings submitted, I consider my interpretations of tracings sent to me to be provided to the patient as a "good Samaritan" in every legal sense of the term.  Patients who have clinically worrisome symptoms and need emergent analysis of their heart rhythm should seek help in an emergency department or call 911 and not expect a doctor to provide an immediate interpretation of their tracing, unless such an arrangement is defined clearly between doctor and patient before issuing the device.  Expecting a doctor to make urgent clinical decisions based on this single-lead EKG app is of limited utility, in many (and maybe most) instances in my view, so patients should look at this device as a convenient adjunct to more conventional medical care.  While it might come one day, the AliveCor iPhone EKG has simply has never been tested for emergency use as of the time of this writing.

So I may do a test run to see how it goes on a test basis but I can already see some legal concerns for doctors who prescribe this device.  Until a clear interpretation workflow is established that can provide comprehensive coverage of interpretations paired with a well-defined and easy-to-use interface with a medical record system, patients should understand doctors' possible hesitation to prescribing this device to a multitude of patients for personal use.

-Wes

The Costs of Not-so-Shared Decision Making

This week's New England Journal of Medicine contains a perspective piece by Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. entitled "Shared Decision Making to Improve Care and Reduce Costs." The original paragraph of the piece sets the tone:

"A sleeper provision of the Affordable Care Act (ACA) encourages greater use of shared decision making in health care. For many health situations in which there's not one clearly superior course of treatment, shared decision making can ensure that medical care better aligns with patients' preferences and values. One way to implement this approach is by using patient decision aids — written materials, videos, or interactive electronic presentations designed to inform patients and their families about care options; each option's outcomes, including benefits and possible side effects; the health care team's skills; and costs. Shared decision making has the potential to provide numerous benefits for patients, clinicians, and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and greater alignment of care with patients' values.

However, more than 2 years after enactment of the ACA, little has been done to promote shared decision making. We believe that the Centers for Medicare and Medicaid Services (CMS) should begin certifying and implementing patient decision aids, aiming to achieve three important goals: promote an ideal approach to clinician–patient decision making, improve the quality of medical decisions, and reduce costs."

What a nice, lovely, fuzzy bunny.  Who couldn't want such "shared" decisions in complex medical care?  Especially nice simple teaching aids for Medicare's top 20 procedures printed at the "8th grade level" that are "brief?"

Doctors, don't you know that this will become simply another box to check on your EMR for Medicare reimbursement? 

And yet the benefits of cost savings that these "shared" decision making tools' will have on health care are assumed, especially when deployed nationwide, despite what the authors claim.  Note that the 2011 Cochrane Collaborative review of the 86 studies they reference said nothing about cost savings.

Doctors know this and so do the authors.

Why else would the authors require a cudgel to impose their "shared" decision making benefit if other real life clinical doctors fail to follow along?

"Providers who did not document the shared-decision-making process could face a 10% reduction in Medicare payment for claims related to the procedure in year 1, with reductions gradually increasing to 20% over 10 years. This payment scheme is similar to that currently tied to hospital-readmissions metrics."

Ms. Lee and Dr. Emanuel, in their zeal to impose their Progressive mindset upon America's physicians have forgotten several important tenets of health care delivery:

• First, decisions made in medicine are each unique to a patient's constellation of medical problems, socioeconomic and cultural background, age, gender, religious beliefs, etc.  In other words: decisions are made in concert with an individual's situation, and not based on the government's desire (necessarily) for cost savings (even if it is couched in euphemisms such as "shared decision making").


• Second, actual cost information (both out-of-pocket and real health care system costs) for patients and doctors will remain shrouded  in secrecy since payers rely on obfuscation of actual cost information to extract their portion of fees before patients receive any value for their dollar.  Also, other similar pay-for-performance measures have already uniformly flopped at demonstrating cost savings.  Then imagine for a moment if the cudgel for shared decision making is imposed.  The potential for a 10-20% Medicare physician fee cut on top of a 30% Sustainable Growth Rate cut that is likely to reappear in 2014 will be untenable for US physicians. 


• Third and very importantly, the ACA legislation has created a whole new "institute" of salaried individuals within government called the Patient-Centered Outcomes Research Institute (PCORI) to develop the authors' soon-to-be-mandated decision aid materials while another branch of government already exists to produce such education aids called the Agency for Healthcare Research and Quality (AHRQ).  Wouldn't our health care system benefit far greater from cost savings by not duplicating services already performed by another government agency? How much, exactly, will the PCORI cost us?


• Fourth, the push to re-invigorate the mass-production of physicians via three-year medical school curricula while simultaneously failing to increase residency slots assures poorer trained, inexperienced doctor-patient discussions about complicated medical issues, not better ones. Shared does not mean better.


• Finally, liability risks remain for doctors caught in these unenviable mandates that fail to recognize the individual complexities of an individual patient's care.  Until doctors sense a modicum of effort for liability reform, they will continue to offer care that exposes both themselves and their patient's to the path of lowest legal risk, irrespective of what teaching aids they give to patients.

Doctors and the AMA should demand transparency in the cost of creating and funding the PCORI and its shared decision making materials, yet another layer in the runaway middleman health care behemoth emerging as the front lines of health care delivery are systematically decimated. 

If that doesn' t matter to all of us, then share away.

-Wes

Some Blogging Insights for Doctors

Nearly five years ago, I started this blog. As you can tell, I gave it a bit of a facelift yesterday. Over the years I have struggled with the question: should I have ads? Will they make my blog look cheezy? Am I less of a purist if I have ads? So I started slow and tried to keep the blog as unencumbered by ads as possible, placing Google Adsense ads in the footer area of this blog. I made about $1-3 dollars per month with that approach. In essence - pretty worthless. But recently I embarked on an Google Adsense experiment. I added one Google Adsense ad below my post of the day and to my RSS feed. That one move increased my ad revenue about 10-fold - not much, but a significant jump up. With my readership, that amount should just about over the cost of renting server space so my co-workers can see the images on my blog at work. (I appreciate my "Deep Throat" contributors at work who contribute ideas for new content here...) Many wonder, why not just use Google's servers for your images? Well, there's several reasons. The main reason is our workplace firewall. You see Google uses multiple servers on which it holds its images. While images might be easily retrieved using their picture manager software, Picasa, the server on which those images might be held might be held at very different internet addresses. This wreaks havoc on workplace firewalls - until I started using my own server (which my employer has approved), many of my images could not be seen by my co-workers. The second reason is simply one of organization - I know where my images are and how they're organized. I can resize them or edit them as I need and place them on my own server for later use and recall. Just my preference. But renting your own server space costs about $150 (or so) per year. (In contrast, Google offers about 5 Megabytes of server space for free - plenty for most - then charges a bit for more) So, to offset this server expense, I have placed some ads on this blog. No I can't quit my day job, but it appears these ads will help at least defray my server expenses. Not to say that I don't market my ads in the sidebar for considerably more. The relative paucity of cardiology blogs out there makes that space valuable for some. But even when I place an ad there for a month or more, I find that the revenue generated will never serve as my day job. (Moral of the story: be nice to your employer - you need 'em). But more importantly, I have found that this blog has opened many entrepreneurial ventures that are much better drivers for revenue than advertising revenue. I'm betting most serious bloggers find this. (Quick definition: a "serious blogger" is anyone who is crazy enough to do this for over three years) Bottom line: Blogs, in and of themselves, are very poor ways to try to make a living, but can open doors. I also have invested in liability insurance for this blog. It costs about $100-$300 per year, depending on the type of blog you have, but my one experience with defending a frivolous "cease and desist" letter that set me back about $14K in legal expenses makes this expense worth it to me. Learning point #2: Be careful, blogs can be risky. There are tons of resources out there to help anyone who wants to start a blog and try to keep with it. Consider reading just about everything at Problogger.net, for instance. I completely understand the challenges for doctors maintaining a blog - it's damn hard work. But it also serves as a useful avenue for teaching, advocating, venting (when done professionally and with an appropriate amount of restraint) and fills a little creative void that I still enjoy. -Wes

Our Upside Down Medical Liability Crisis

I had an interesting visit with the husband of my niece last evening. He works as an ER doctor that is self-insured group of 60 physicians that cover the ER needs of four hospitals in Clark County near Las Vegas.

What is interesting is they are self-insured to save costs. As a group, then, they know how much per patient they must collect to assure liability care for every patient that comes to their emergency rooms.


That amount is $17 per patient per visit.

Guess how much their group receives for care they render to a Medicaid patient for a "level two" visit (minor problem: ear ache, sore throat, etc.)

Fourteen dollars per visit.

(Note: Medicare level two patients pay considerably better (about four times as much)).

When liability costs exceed the payments received for the care provided to those most in need, it's interesting that our legal and political forces in Washington see no need for liability reform as part of our larger health care reform efforts underway.

-Wes

Missing Judgement

A while back, I gave an EKG challenge to the blog-o-sphere to review an EKG of a young man who presented to the Emergency Room for evaluation of shortness of breath and lightheadedness unrelated to exertion. After posting the EKG, I got all kinds of answers for the young man's ailment, but most failed to guess the gist of the exercise: that the EKG was normal.

It is interesting to ponder why.

In medical school, we are trained to develop a differential diagnosis to any and all symptoms before us. Heck, I can remember the pneumonic "VINDICATES" that allowed me to spew forth such great diseases caused by vascular, infectious, neoplastic, degenerative, iatrogenic, congenital, autoimmune, traumatic, endocrine or neurologic ("squash") causes for virtually any unusual finding on a chest x-ray or lab test. It's how we were trained. Think of everything. Don't you dare miss anything, lest you be judged incompetent in the Court of Public Humiliation on rounds with your Chief Resident or Attending. Cover all the bases. Your patient depends on it.

More senior and experienced attendings usually performed the same exercise, albeit at lightning speed. They quickly consulted their vast experiential database to prioritize the most likely diagnosis, leading to a razor-like ability to hone in on the problem and affect proper treatment. Nine time out of ten they were right on, and we stood in awe. Years ago, that was good enough. Attendings were appreciated for their remarkable accuracy but permitted the professional courtesy of occassionally missing a diagnosis. Naturally as residents, we relished the moment when we got it right when the attending didn't: those cases were always presented as "The Case of the Week" conference on Fridays where we rehashed the play-by-play of our diagnostic acumen. It was how we learned.

But with the evolution of the information era, the remarkable improvements in radiologic image quality and test performance, and the speed with which those images and test results are acquired and reported, deductive reasoning and judgement in our Emergency Rooms and offices based on careful history and physical examination has given way to a plethora of testing. God forbid you miss something. Better to shot-gun it rather than limit it. It is far easier to explain a negative test finding than a missed diagnosis. But what about the unexpected findings of, say, a positive troponin from a person with an inflamed toe from gout? Should a cardiologist be consulted? What are the risks to the doctor if there is a heart attack underway?

With the constant drumbeats of "quality" and "safety" echoing in doctors' heads coupled with shortened office visits and overriding liability concerns, a psychology of professional protectionism has come to trump judgement. There simply is no reward for proper judgment in our system, even though there are lots of reasons for false positive troponins. But it is difficult to explain this to a concerned patient and only huge financial and emotional downsides if you're wrong.

So the cardiologist is consulted, the echo obtained, and the nuclear treadmill performed, even as our judgment tells us otherwise.

It's just too risky to do otherwise. After all, it only takes one subpoena.

But as we limit doctors' salaries, drug costs, restrict certain testing (as much as we can), and limit hospital stays as much as we can through policy after policy, we must ask ourselves why we consistently fail to limit liability as the costs continue to spiral ever higher.

Up and up and up.

But limiting liability would require some judgement now, wouldn't it?

-Wes

Should You Have Blogging Insurance?

Digital Pathology Blog contemplates his liability needs as a blogger. I would encourage this given my experience, particularly if "whistle-blowing" or ranting occurs on your blog. Some offerings for bloggers insurance are mentioned here. I'm still shopping options and readers will likely see advertising creep in to my blog to offset expenses.

I'd also encourage all bloggers to understand the legal definitions of defamation, slander, and libel.

-Wes

References:

My Problem: "Bloggers Beware"
Where I try to decide if I should continue blogging: "So Now What?"
From the Daily News / Opinions: "Bloggers Must Learn A New World Order to Win Fans, Respect"
Electronic Frontier Foundation Cyberslapp Website.