My Blog

January 18, 2014

The Death of the Progress Note

Filed under: Uncategorized — Tags: , , , — admin @ 6:03 pm


I am not sure of the date or time of death. However, I am reasonably certain of the cause. Death was by electronic data and formatting. The victim was the time-honored physician’s progress note. To be sure, these notes, even the now “ancient” written ones, were far from perfect. Shortcuts such as “as above” or AVSS (All Vital Signs Stable) littered the pages of the now nearly extinct hospital chart. Yet, what now replaces it more resembles “computer vomit” than anything readable or coherent. The EHR is drowning in data excess where the truly pertinent information is at best lost is a sea of cut and paste gobbledygook, and at worst, repetitive false information.

The designers of the EHR sowed the seeds of this mess. Initially computerized health records were created to more accurately bill medical procedures, CPT codes, and hospital services. Clinical information was added out of necessity, but layered on a framework of billing and coding, making a very imperfect marriage as the final product. Having used our office EHR now for ten years, and learned four different hospital systems over the past few. Thus, I have seen more than my share of this landscape, and trust me, it isn’t pretty.

I have worked with IT personnel to try and make my notes more readable and coherent, and have used everything from larger fonts, to SOAP formats. But in order to comply with coding requirements for mid-level and higher coding, I am forced by Medicare to throw in stuff that is redundant and clinically useless. For example, “No change in PMH/FH/SH/ROS.” (Translation: Past Medical History, Family History, Social History and Review of Systems.) Since it is unlikely that my patient with CHF or atrial fibrillation will remember a new symptom, or discover a family member had a stroke, between day one and two of his hospitalization, this exercise is a waste of time, but required by CMS if you want to be reimbursed for a complex visit.

I review my patients’ medication administration record, (or MAR), daily. However, if I document those medications in the record, the end result may be a morass of unorganized and scattered drugs. The worse offender here is the Meditech system used by HCA hospitals. When incorporated into the progress note, the list is neither alphabetical, by date or route of administration. In other words, it is a disorganized mess. This quirk has been pointed out to the Meditech IT staff, and they say they have forwarded the doctors’ “concerns” to the programmers, who say they are “working on it.”

The other issue with the electronic progress notes is the “carry forward” features. The Meditech physical exam auto-fills from the previous day, unless you specifically change it. This is nice for the time pressed doctor, but leads to false and inaccurate documentation. I have seen patients who days following extubation still have noted an ETT in the mouth. In order to keep the physician “honest,” you must fill in “General Appearance” daily, but the rest can be an all too easily repeated. Ditto for the Impression and Plan. Again I have noted plans like, “For bypass surgery” a day after the procedure was completed. In its defense, you can free text anywhere, but that takes work and typing skills, and many older doctors simply are lacking here. And the local HCA hospitals have refused to install voice recognition software to make the docs’ jobs easier.

Other hospital systems force the doctor to refill the H&P daily, but there are auto-click buttons, which when repeated daily are obvious cookbook catch phrases. You can free text for sure, but again that takes more time. Local Baycare hospitals have thankfully installed proprietary voice recognition software to accommodate the “keyboard-challenged” physicians.

The end result is often a misleading and unhelpful recording of the day-to-day patient’s progress. There seems to be more than enough information in the notes, it’s just that the “forest in lost inside all of the trees.”

I place the blame at the feet of CMS and insurance companies. They are the ones who have created this checkbox and laundry list approach to medical documentation. That is if the doctor wants to get reimbursed for anything above the simplest visit level. I review others notes and have to search for nuggets of informative prose. Emergency department notes are even worse. It takes effort to sometimes find out why the patient even sought urgent care.

There must better information systems around. Unless we can free ourselves from being reimbursed by the number of words in a note, I fear the valuable physician progress note will continue to drown in mountains of data and illiteracy.

October 23, 2013

Guess What Might Just Save Healthcare

Filed under: Uncategorized — Tags: , , , , — admin @ 2:30 pm


If you are like millions of Americans, at some point in your adult life, your doctor will order you to have a CT or MRI scan. Quick, easy, and painless, (unless you have claustrophobia), these invaluable imaging tests provide a vast amount and array of diagnostic information about illnesses, and direct treatment paths. However, the real pain usually begins when you receive the bill. It is not uncommon for the charges, including radiological interpretation, to run into the thousands of dollars. However, as those of us in the medical field know, “charges” do not = “costs.” So what exactly is the cost of these tests? Good question.

It is not uncommon for a MRI, (Magnetic Resonance Imaging), to cost $2,000-$5,000, depending upon where it is done. So how about charging just $275 for the test? Sound like a myth or joke? It isn’t, if you go to Affordable Medical Imaging, ( So here’s the catch: they do not accept insurance or fill out insurance forms. Neither do they wait for payment. The patient pays the bill at the time of service, and the company gives the interpretation results and billing information to the patient. The patient may then submit it to his or her insurance company for payment.

How can they do that and still make money? The answer is easy. Without having to bill insurance companies and wait for authorizations and payments, the supplier to consumer short cut saves thousands of dollars in overhead costs. It may come as a shock to many, but health insurance is in large part the problem, and not the solution, to not only skyrocketing health care costs, but also access to care in this country. Insurance sets the rates of payment, including Medicare, (which by the way is the worst offender), and thereby increases overhead for hospitals and doctors. Since Medicare “rules the roost” over how providers get paid, and how much, they have no competition. One of the immutable laws of economics is that no competition=increased costs. This is true whether you are selling hamburgers or imaging tests.

One of the problems with health insurance in the US is by its history and very nature; it functions like no other insurance product. Imagine if your automobile insurance was forced to pay for preventive maintenance and oil changes. Or your homeowner’s policy covered a couple of shingles knocked off a roof in a storm. If they did, then how affordable to you think those policies would be? Every time insurance is excluded form the equation in medicine; prices go down––think LASIK and plastic surgery. Insurance, by its very nature, is meant to cover episodic large, often unpredictable, events; not everyday minor problems.

The difference however between health insurance, and others, is the implicit belief that everyone, no matter how rich or poor, is entitled to basic coverage for illness and accidents. Although still somewhat controversial, it is this essential belief that makes that coverage either very expensive, or not accessible, as in rationing. Unless this paradigm changes, and I doubt it will, medical insurance will continue to escalate and health care more difficult to access.

To be sure, not everyone can afford high deductible health insurance plans. Although the Affordable Care Act, (a.k.a., Obamacare), will reduce premiums for some, it will raise them for many more. Yet, if the truly free market were permitted to grow in health care, prices could only come down for everyone. Imaging is the easiest place to have price competition as Affordable Medical Imaging demonstrates. But there is absolutely no reason why it couldn’t be done in other medical and surgical fields as well.

Medicare, as an arm of the government, changes reimbursements for often arbitrary and political reasons. As an example, up until a few years ago, there were 100′s of freestanding cardiac catheterization labs across the US. That was until Medicare decided to reduce payments to these labs below the actual level of costs. No matter that most labs could do a heart cath, charge between $1,000-2,000, (including facility fees and professional charges), and still make a profit. Instead, and due solely to favored payments, outpatient heart caths went back to the hospitals where charges for the same procedure are typically between $5,000-$10,000. That is an example of how preferential pricing can be a major driver of health care costs.

The roadblocks are substantial. The medical insurance and hospital industries have vested interests in keeping costs high. And as long as we view the holy grail of medical care being equated with having similar insurance for all, costs will never become significantly lower, and access will be come more two-tiered. Sometimes the simplest solutions are the best ones.

October 19, 2013

You might want to be a doctor if

Filed under: Uncategorized — admin @ 7:00 am


You are young and bright and starting to think about a career. Maybe you are graduating from high school or in college, or floundering around part-time in some tech job. Here are 10 questions to ask your self:

1. Do you love spending lots of time everyday on a computer, Smartphone, or tablet?
2. Do you have a high level of frustration?
3. Do you enjoy making life and death decisions, but also don’t mind having them reviewed by a bureaucrat or regulating body?
4. Can you excel at multi-tasking and don’t mind being interrupted dozens of times a day?
5. Are you flexible enough to learn new rules and regulations at work daily?
6. Can you type or keyboard really fast, (say like at least 50 WPM)?
7. Can you handle someone else telling you how long you can spend with a customer? Whoops, I meant patient.
8. Are you challenged by a lifetime of perpetual course taking for re-certification of things you already know and do well?
9. Do you consider it a challenge to learn an EMR designed by a non-clinical programmer?
10. Do you consider it stimulating to diagnosis and cure disease but at the same time try to avoid a malpractice suit in case you are wrong or err?

If you answered yes to most of these questions, then I’ve got the career for you, young man or woman––become a doctor. Yes, some of the above is tongue-in-cheek, but my observations of the present state of medicine, tells me it is not too far from the truth. I have the advantage of the long view, having graduated from medical school in 1974 and been in private practice since 1979. A lot has changed––some for the better, and lot of it not.

What I do see is many of the doctors my age are choosing to retire early out of sheer frustration. The younger doctors don’t know any better, and seem to accept many of these roadblocks to good patient care as “normal.” They even seem to enjoy the challenge. But herein lies the paradox. As a general rule, many of us chose medicine because it offered autonomy and the satisfaction to heal the sick. Yes, it has paid well, but we delayed entry into the labor force by 10-15 years. And the salaries are only headed downward.

Sadly now a typical physician spends more time on a computer than talking to, or examining, a patient. Ditto for the nurses. The trend in public policy is to expand healthcare coverage to more people, which is a lofty goal indeed. However, within the thousands of pages of ACA (Affordable Care Act, AKA, Obamacare) are no provisions for increasing the number of doctors to care for new patients who sign up. (That is assuming the Health & Human Services actually creates a functional website.) What I foresee is a perfect storm for shortages in healthcare providers.
Older physicians, like myself, will give up in disgust, and less young people will choose this profession. More care will be provided by “physician-extenders”, like nurse practitioners or physician assistants. More hospitals will sponsor marginal quality “teaching programs” with questionable community doctors as the instructors, so the hospital can rake in millions of federal Medicare money. In October of 2014, ICD 10 will be implemented making a coding nightmare for doctors and their office staff. As an example, envision 12 ways to code for infections of the hand. Solo and small group offices will be forced to close, collapsing under the weight of bureaucratic and regulatory rules gone wild.

I would like to be more optimistic, and hope that I am wrong. After all, peers, my family, and I will need more, not less care as we age. However, unless something fundamental changes, we are headed to a homogenous and less available system of health care in this country. Increasing the number of medically insured does not guarantee increasing their access to care.

August 19, 2013

The Schizophrenia of Hospital Discharges


A long time ago, in a bygone era, hospital discharges were simple. As a physician, you decided when to admit and discharge a patient from the hospital. Unfortunately, this process was often inefficient, costly, and subject to the whims of doctor and patient. Medicare, and other third-party payers, ultimately realized that this format made little sense and motivated keeping patients in the hospital too long. Many unethical doctors gamed the system by ordering questionable consults, insuring excessive lengths of stay, (LOS). As an attending physician, the longer the LOS, the more money they made for daily hospital visits. Sadly, to some extent, this practice still exists today. In the early 1980′s, Medicare instituted its Diagnostic Related Group, or DRG payment method, which capped hospital reimbursements by a given diagnosis, rather than upon a per diem basis. So the longer the patient stayed in the hospital, the more money the hospital lost. Conversely, the shorter the stay, the more money they reaped. Doctors, except for surgeons who did an operation, were excluded. Thus doctors and hospitals became entrenched on polar ends of the incentive equation.

This misalignment of financial incentives was a major factor in the birth and popularity of the new Hospitalist specialty. Of inpatient Medicare claims for internists, the proportion handled by hospitalists jumped from about 9 percent in 1995 to about 37 percent in 2006. The percentage today is much higher. Often employed by the hospital, the latter now had the muscle to hurry the patient out of the in-patient setting, which increased the facility’s profits. Alternatively a hospital group could be contracted for services by a hospital. If it’s LOS profile was less than satisfactory, the contract was not renewed or voided. But the hospitals faced another thorny issue. That was how to get the majority, if not all, of their in-patients admitted to the hospitalist’s service, and not that of a community physician. To mandate this would be in direct violation of many medical staff bylaws or rules and regulations. Some have done so by so-called “economic credentialing”, pressuring credentials and Medical Executive committees, to not renew admitting privileges of “over-utilizers.”

Others, like one local hospital, simply ignored the medical staff’s rules and regulations, and instituted a policy of all “unattached” emergency room patients needing to be admitted by a hospitalist. Faced with declining hospital reimbursements for visits, may family doctors quickly figured out they could make more money by seeing office patients and reluctantly, or gladly, relinquished admitting duties to the hospitalist. As a result, patient care has not always improved, and in others, actually suffered.

Studies found that although the hospitals saved money with hospitalists in charge, Medicare didn’t. Often hurried out of the hospital before stabilized, re-admission rates began to climb. This “revolving door” consequence cost Medicare, and other insurers more, but increased the hospital’s profit. You see, even if a patient was discharged, and re-admitted one day later, the meter would be reset and a new DRG payment to the hospital was initiated. Perhaps slow and inept, Medicare is not completely dumb. On October 1, 2012, they started to financially penalize hospitals for “excessive” readmissions. The penalties involved are not small. If the readmission rates go above a certain percentage, the fine can be in millions of dollars. And the readmissions are for anything and anywhere. So if a patient in Miami is discharged from a hospital with congestive heart failure, and then is admitted in Michigan within 30 days of discharge with pneumonia, the Miami hospital is dinged. The actual rules of Medicare’s Hospital Readmission Reduction Program, which was birthed as part of ACA or Obamacare, are too complex to detail in this blog.

However, suffice it to say that now the “shove them out the door” policy perfected by hospitalists may backfire, and cost the institution more money than it saves. This schizophrenia of hospital discharging gets even more complicated when you consider that realistic fears of litigation drive many ER physicians to err on the side of admitting, rather than discharging patients. In answer to this, some hospitals are now experimenting with utilizing hospitalists in the emergency room

This has left a muddy picture for patients, and their families, caught in the middle of what is in essence more of a monetary, than quality of care, battle. Ultra-short, or long, hospital stays are often not in a patient’s best interest. Sadly, we may have replaced a costly and at times inefficient system, with one driven purely by the “best reimbursement profile” of the day. Ideally, it would be great if third party payers supported and preferentially directed its patients to centers of excellence, where patient discharges are neither too early not late, and can prove good clinical outcomes. How to measure and evaluate this will not be easy, but it is certainly not impossible with today’s metrics and wealth of health outcome data.

July 27, 2013

Another French Paradox

Filed under: Uncategorized — admin @ 10:06 am


The French Paradox is the observation that French people suffer a relatively low incidence of coronary artery disease (CAD) despite having a diet relatively rich in saturated fats and cholesterol The term French Paradox was coined by Dr. Serge Renaud, a scientist in France and made popular when described on the CBS news show “60 Minutes” in 1991. The theory goes that the French people’s large consumption of red wine helps to decrease the incidence of CAD by as much as 44% compared to other Western countries, in particular the United States. Other theories such as low genetic predisposition to CAD in the population and generous consumption of fresh fruits and vegetables were largely ignored. Also not mentioned was the leading cause of death in adult French males––cirrhosis of the liver.

But this is a curious topic for another time. I have recently observed something else about the French while my wife and I traveled for two weeks in Europe. We were in five countries: Germany, Switzerland, France, Belgium, and the Netherlands.
My wife made the interesting observation that most of the obese people we saw were Americans and not the natives. Our friends, who live in Amsterdam, also said many were Eastern Europeans. Nonetheless, I too was struck by the relative slimmer size of the Western European people. As a cardiologist, I started to ponder the paradox. Here were people who lived on bratwurst, beer, pretzels, chocolates, and pastries, and yet compared to pot-bellied Americans, you would think they were all Vegans.

Maybe it was because so many of them smoked I mused. Then I envisioned all of my obese patients who were smokers, and tossed that theory out. Next was the portion theory. Sure our portions are huge here, but what we ate at restaurants in Europe was far from tiny. There were some other clues. Here in the states, I suffer, as many adults do, with lactose intolerance. Yet, in France, I ate cheese, butter, and cream with little indigestion or flatus––yet another puzzle.

My wife, the artist, has a theory. She is convinced that food additives and preservatives are the culprit. Indeed a quick Internet search revealed that there are over 1,400 man-made chemicals added to the American food supply today. There are “natural sweeteners” as in high fructose-corn syrup, artificial sweeteners’, and “natural flavorings”, meaning annatto or guar gum, etc. A whole cottage industry of “chemical cuisine” has taken over much of our foodstuffs today. In my mind, the health impact and contribution to our obesity epidemic is unknown, undefined, and suspect.

So as we made our way through a veritable gustatory journey of overtly high fat and high caloric food, my thoughts turned toward my waistline. Since age forty I have added about a pound a year, and my self-image as a “slim” person has been in jeopardy. I weighed myself before leaving for Europe and two weeks later upon return.

Despite sinful indulgences such as pretzels, beer, Belgian French fries, (or pom frites, minus their traditional mayonnaise), French bread, pastries, and hot chocolate so thick you could stand a spoon up in the cup, I was stunned at my weigh-in. I had gained only one pound!

I don’t think I’m any closer to an answer about this paradox than I was before our trip. However, I am starting to agree with my wife––the food industry is poisoning us. I can’t back this up with science but my anecdotal travel experience has me concerned that something seriously wrong is happening with our food supply on this side of the pond.

So now I read labels like a detective, shunning anything that is packaged with more than five ingredients. And if you think that is easy to do, then just try grocery shopping sometime and reading all of the food labels. It will be a real eye-opener. In the meantime, we will continue to shop at Farmer’s markets, grow veggies out back in our Earth Boxes, and eat out as little as possible. I don’t care if it is high fat, lo carb, no fat, etc. What might be more important is and how and where our foods are produced than anything else.

July 8, 2013

Misplaced Medicare Incentives Are Driving Healthcare Costs Upward



For all of those out there anticipating the 2014 official role out of Obama Care, officially known as ACA (Affordable Care Act), here is a cautionary tale. Many years ago, as I was growing my cardiology practice, it became evident that diagnostic services for my specialty, like stress tests, echocardiograms, etc., were done less efficiently and cost more at the local hospital, then in the office. This stimulated many groups in the 1980′s and ’90.s to install their own “ancillary” diagnostic services. Patients loved not having to deal with the long waits and higher co-pay prices at the hospitals. And yes, the cardiologists did increase their revenues with these tests. However, lower costs to patients, insurance companies, Medicare, and improved patient satisfaction were just as powerful a stimulus to the explosive growth of these diagnostic tests, and later even cardiac catheterization labs, when integrated into the physicians’ offices.


As the growth in testing spiraled upward, the hospital industry saw their slice of the outpatient revenue pie nosedive. Hospital lobbyists and policy-makers cried foul and complained of greed and self-referral, which they said was spiking the rapid rise in healthcare costs. Studies laying blame on self-referrals being the major culprit for escalating healthcare costs, have been inconclusive. However, after years of lobbying and the passage of ACA, the hospital industry finally had the weight of the Federal government on their side. It did not take long for Medicare to start dialing back the reimbursements for in-office ancillary tests and procedures, and outpatient cardiac catheterization labs were one of their main targets. Hospitals had lost millions of dollars to the burgeoning growth of these labs inside the cardiologist’s office.


Our twelve-man group had a safe and successful lab for about ten years. Then after ACA was passed, Medicare began to cut the reimbursements for global and technical fees in this area. The cuts were so Draconian that it became impossible financially to continue the service. Never mind that we could provide the same service as the hospital more efficiently, with better patient satisfaction, and at a third of the cost.


Other diagnostic tests are being similarly placed under the reimbursement gun. Fiercely independent as a group, cardiologists have finally given up and began selling their practices to hospitals where they could be reimbursed based upon their work, (or RVU), and not worry about reimbursement from insurance and Medicare. So powerful has been this incentive that at the end of 2012, it was estimated that more the half of US cardiologists had sold, or were in the process of selling, their practices to hospitals.


But now Medicare and Congress realize they may have made a mistake. A federal advisory panel just said that Congress should move immediately to cut payments to hospitals for many services that can be provided at much lower cost in doctors’ offices.


So after taking measures to increase the cost of care and testing, it has finally dawned on them that they have incentivized the wrong entity. Unfortunately the Genie has left the bottle, and it is unlikely that the steady tide of cardiology groups selling their practices to hospitals will be stemmed. The end result will of course be higher costs to patients, insurers, and Medicare.


How bad is it? For example, Medicare pays $58 for a 15-minute visit to a doctor’s office and 70% more, $98.70, for the same visit in the outpatient department of a hospital. The patient also pays more: $24.68 rather than $14.50. When a patient receives an echocardiogram in a doctor’s office, the government and the patient together pay $188.  They pay TWICE as much, $452, for the same test in the outpatient department. From 2010 to 2011, the number of echocardiograms provided to Medicare beneficiaries in doctors’ offices declined by 6% while those in hospital outpatient clinics increased by 18%. Perhaps ACA should be renamed the “Unaffordable Care Act.”


The federal advisory panel now realizes that the hospital buyouts of doctors, which have turned independent practitioners into hospital employees, has led to higher spending by private insurers and higher co-payments for their policyholders.


So where is the accountability here for the original poor judgment and decision to attack the cost-saving independent doctors’ offices and labs? No one has been named in this advisory panel’s report cited above, and I doubt anyone will ever be held responsible.


This is the kind of government snafu we have to look forward to with ACA­­––skewed incentives based solely upon lobbying and misinformation. Truly free market forces, which we have never had in medicine since the passage of Medicare, restrain costs. It is unlikely that the clock can be turned back, but I am betting that more increases in cost will result from ACA then savings.




March 2, 2013


Filed under: Uncategorized — Tags: , , — admin @ 5:05 pm

Juan Gonzales, (not his real name), is a somewhat demented elderly Hispanic male, who I met last week in an intensive care unit. He spoke little English, and I spoke limited Spanish.  His devoted family was at the bedside, and fortunately his daughter was able to provide some history. He was admitted with palpitations and dizziness and atrial fibrillation with a rapid response. His family had just moved him from Miami, where they said he had three prior strokes. As I went over his medications, all seem appropriate except for two antibiotics ordered from the ER, azithromycin and ceftriaxone. He had no fever, a normal white blood cell count, no cough or dyspnea, and benign urinary sediment. His lactic acid level was also normal. His chest X Ray did show heart failure and the report also said “cannot rule out lower lobe pneumonia.” By all clinical and objective criteria, this man did not have an infection that needed to be treated. However, the ER team is so sensitive to missing sepsis that I guess any reason to give empiric antibiotics is not missed.


I have witnessed this trend before, and have to wonder how much this over use of antibiotics has contributed to drug resistant bugs in the hospital.  As a physician in training, we had a fraction of the drug resistant problems encountered in most hospitals today. I can’t believe that our hand washing and sanitizing was that much better in the “old days.” I am no infectious disease or public health specialist, but I do believe that the unintended consequences of this, and other mandated core measures and protocols, have created as many problems as they have solved.


There certainly is a role for guidelines and workflows. I am sure that more post-MI patients are discharged on aspirin, beta-blockers, and statins, than before they were instituted. Yet, the cookbook approach to medicine also makes us clinically lazy and treating problems where none existed. I have had to wage a campaign at some of my local hospitals to educate the coding folks, (not so fondly referred to be one nurse as the “clipboard people”) to not say a patient has congestive heart failure, because his B-NP level was 102 (normal being 1-100).  And therefore I don’t need to order beta-blockers, ace-inhibitors, or an echocardiogram.


Speaking of echocardiograms, if the patient had one last month and returns again in heart failure, he really doesn’t need another one, unless of course he has had an MI. Probably one of the most abused and over-ordered cardiology tests, doctors and coding staff seem too rushed to even look if the patient has had an echo in the recent past. And oh by the way, Medicare won’t reimburse us for reading more than one every six months, without an appeal and extra documentation.


Another time I was approached by a core measure nurse, to ask why a patient had not gotten aspirin within 24 hours of his admission. The answer, which of course I had to document in the chart, was because the poor soul was in shock and on a ventilator, and his enzymes did not turn positive until 36 hours after admission.


The Joint Commission has now recommended no less than 14 different “National Hospital Quality Measures”, ranging from Myocardial Infarction to Tobacco Treatment. So expect the ranks of the clipboard team to swell in the future. Some of these make sense and are useful, like a “timeout” before surgery or an invasive procedure, to make sure the correct patient and site of operation are confirmed. But do I really need a timeout before I administer a treadmill stress test?


All of these policies are well intentioned. However, once Medicare started supplying financial incentives, and disincentives, and the Joint Commission penalized hospitals for poor compliance, you knew abuses weren’t far away. I suppose as doctors, we had this coming for not remembering to do all those little things that make patients better, and avoiding those that make them sicker. It just seems that common sense has once again taken a back seat to bureaucracies and insurance companies.


I do what I can, albeit small, to make application of these guidelines more rationale. But sometimes, I feel like Don Quixote, tilting at windmills. As for Mr. Gonzales, I stopped his antibiotics, treated his atrial fibrillation, and he did just fine.




Filed under: Uncategorized — Tags: , , , , — admin @ 5:03 pm

I recently sat in a small room, in the bowels of a local hospital, training for the impending implementation of CPOE. For those not familiar with current health care acronyms, this stand for Computerized Physician Order Entry. Nearing the end of my medical career, I could not help but admire the timing of this phenomenon. “They’ve finally done it,” I mused silently. They have replaced the medical secretary with none other than the physician. I supposed this was inevitable. After all, for years now I have been stuffing my own charts with order sheets and progress notes, applying patient labels to same, retrieving my own lab and radiology reports, etc. This was just the logical conclusion

But for one who has been an EMR advocate, the irony did not escape me. For almost ten years now my cardiology group practice has had an EMR, and although it took me a good 6 months to become comfortable with it, I now couldn’t imagine going back to a paper chart. So why is the hospital equivalent so painful for myself and many other older doctors?

Lack of compatibility and conformity is one big reason. I am on staff at six local hospitals, which have three separate electronic health records. That means learning the ins and outs of three completely different means of accessing and inputting data. There are three different sets of user id’s and passwords, which change at different times and all with variable character requirements. If I read EKG’s or diagnostic studies, it is probable that I must use a different application with other unique id’s and passwords as means of navigation.

How bad is it? Well, because of this, and other personal applications that I access, I succumbed to a password keeper application. In less than six months, I now have about 75 different apps, or programs, passwords, which are now kept quite nicely on my IPhone, IPad, home computer, and in the “Cloud.” For those of you technologically challenged, the “Cloud” is a mysterious data storage area kept in a baffling location, holding onto a humungous number of bits, (or is it bytes?), of information all over the world. You can dump, and retrieve, data into and out of it with the touch of a keystroke. (Provided of course that you remember the correct use id and password.)

IT, or information technology, is a wonderful thing. Yet, because of the ease, and wealth of information that can be handled, there is a tendency to abuse it. How much better is my life after reading, (or deleting), 100 or more emails a day? Do I really need a weekly e-mail update from the medical staff secretary about which drugs are now unavailable due to a “national shortage?” If I order it, and the pharmacy doesn’t have it, they will let me know, and I will order something else.

It is easy to loose site of the fact that IT is just a tool, and like any tool, can be used to improve our lives, entertain us, or to do evil, as in identity theft. My gripe is that is the push for a nationalized electronic health record has come without any true means of having seamless integration of the multitude of programs. Few records, like hospital and physician offices, “speak to each other” electronically, and therefore create as many problems as they solve. Physicians’ efficient use of preciously limited time has become another victim.

We were sold a false bill of goods. Optimistic predictions by a RAND study in 2005 helped drive explosive growth in the electronic records industry and encouraged the federal government to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place. (And oh by the way, RAND’s 2005 report was paid for by a group of companies, including General Electric Co. and Cerner Corp., that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, from $1 billion to a projected $3 billion in 2013.) But evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services. Whoops.

The US health system is so large and heterogeneous that it is virtually impossible to integrate it in a seamless fashion. Imagine if we could carry around a microchip that stores all of our medical history and testing so any health care provider could access it instantly. So if you just had a coronary stent a few years ago in Miami, and while vacationing in Seattle you have chest pain, a local ER doctor can instantly read your old EKG and cath reports. Now that would be progress and provide potentially billions in savings. Of course there are privacy issues to overcome, but don’t tell me that the technology is not there to accomplish this.

We must standardize more. A decade or more ago as diagnostic studies became increasingly computerized, the cardiology and radiology fields faced a similar crisis. Ultimately, a universal display format called DICOM, was adopted, so viewing studies anywhere on any computer was feasible.

This is the only way for medicine and IT to become maximally useful and make doctors more efficient. Hopefully someone will spearhead this effort, but I will likely be retired and out fishing on my boat by then.

January 19, 2013

Guns, Doctors, Patients, and the Second Ammendment

Filed under: Uncategorized — Tags: , , , , — admin @ 10:41 am

Recently both President Obama and the AMA have called for physicians to talk with their patients about gun ownership, especially if they sense mental health issues. This request sounds innocuous enough, but let’s explore the implications and the reality here.
First I need to issue a disclaimer. I am neither a member of the NRA nor do I necessarily feel that more gun laws and bans will reduce the recent tragedies in Newtown, Ct. or Aurora, Co. Gun safety should be of paramount importance to all gun owners. However, if I am going to ask all my patients about gun safety and ownership, then there are a few other dangerous things I need to engage them with as well.
“Do you own a pool?” (Quite relevant since we live in Florida.) “If you do, do you have small children at home or as guests? Do the neighborhood children come by? Do you have a pool fence and is it locked at all times? Have you thought about how many accidental drowning of children there are in Florida every year? Have you taken a course in pool safety?”
Or how about this topic: “Do you own a dog? What kind of dog is it? Were there any pit pulls in its family lineage? Do you have small children at home or grandchildren? Has your dog ever bitten anyone? (Okay, the mailman doesn’t count.) Have you taken a course in dog safety ownership?”
You see where I am going with this of course. First of all, I, and most doctors, don’t have the time to engage in this dialogue with my patients, since I am too busy asking about percentage of seat belt use, quitting smoking, updating medicine lists and system reviews, and filling out ridiculous “meaningful use” of EHR forms, just to get paid from Medicare. And even if I did have time, it is really none of my business. And if even if it was my business, asking this would not prevent a mentally aberrant person from finding weapons and using them in a hideous fashion.
The fatal flaw in this logic is that the desire to do good, does not lead to good results. In fact the opposite is often the case. A recent Opinion piece in the Wall Street Journal, (January 16,2013), by Jeffery Scott Shapiro highlights this paradox. He was a criminal prosecutor in the District of Columbia from 2007-09. In essence, during the strictest gun ban years, the rate of homicides increased. Ultimately in 2007, the U.S. Court of Appeals in D.C. ruled the city’s gun ban to be unconstitutional. The US Supreme Court also affirmed the ruling the next year. Since the ban was struck down in 2008, the homicide rate dropped from 186 to 88 in 2012, the lowest number since the original ban law was enacted in 1976.
Recent shooting tragedies do launch a knee jerk reaction by well-intentioned politicians, but as usual, the beneficial results of new laws often achieve the opposite, since the criminal, or deviant mind, will always find a way to purchase weapons. So following are my thoughts on what might help.
Loosen the HIPAA laws so deranged individuals can have their psychiatric history quickly accessed by mental health providers. Tighten the “gun show” loopholes, so gun purchases meet the same measures at shows as at a gun store. If the government insists on throwing more money at a problem, (and they excel at always doing so), then invest in more mental health professionals and treatment facilities. Make it easier for teachers, (who want to), learn gun safety and obtain concealed weapons permits. Every adult who supervisors school outings in Israel is trained in weapon use and carry semi-automatic guns on field trips. You never hear about these tragedies in that country.
But mandating doctors to ask patients about gun possession? You can count me out on that one. This is an invasion of privacy, and worse, will do nothing to curtail the periodic catastrophe that occurred at Sandy Hook.

–– “To be prepared for war is one of the most effectual means of preserving peace. A free people ought not only to be armed, but disciplined.”
– George Washington, First Annual Address, January 8, 1790.


September 16, 2012

Rethinking Health Insurance

Filed under: Uncategorized — Tags: , , — admin @ 4:36 pm


Recently a neighbor backed into my car while I was leaving a food store. The damage was minimal, but she offered to have her insurance company pay for the repair. After contacting the company, I was offered several body shops, and chose the one closest to my home. The work was completed in only two days, and while it was in the shop, I decided to also have some dents and scratches fixed, which were unrelated to the accident claim. To my surprise the mild fender damage, which was covered by the other driver’s company, was paid in full without an estimate. The amount was approximately $500. A scratch on the other side, and four dents, were repaired, for which I paid separately a little over $400. So I spent, (out of pocket), for three times as much work, and paid less than the insurance company did. This got me thinking about how insurance adds to the costs of services in the auto industry, and how that might be relevant to health insurance.

Having practiced medicine for over thirty years, I am convinced that when it comes to the cost of healthcare and insurance, insurance is the problem and not the solution. Health insurance is not sold in a truly free market, like home, disability, and life insurance products, etc. Let’s look at some parts of healthcare where traditional insurance does not cover the cost of the service. In his excellent book on this subject, “Priceless,” John C. Goodman, states the case quite well. LASIK eye surgery and “cosmetic surgery prices, rarely covered by insurance, has been falling over time in real terms––despite a huge increase in volume and considerable technical innovation (which is blamed for increasing costs for every other type of surgery).” Since insurance does not dictate the prices and reimbursements for these procedures, doctors are free to repackage their services competitively, and patients are free to negotiate.

Even how health insurance functions in this country makes it quite different than all other insurance products. Automobile insurance protects against unforeseen and catastrophic events, such as a vehicular damage, theft, and human injury. There is no “preventive” insurance as seen with health care. If I pay a premium to GEICO, it does not cover the cost of tire rotations, brakes, new batteries, or oil changes. Similarly, homeowner’s insurance pays for storm damage to a roof, but not the price of roof replacement from normal wear, tear, and aging. Even the assumed theory that preventive care reduces overall health care expenditures is arguable.

Part of the difference may be historical. Post WWII, employers were not allowed to raise wages, so to attract better employees, they began to offer health insurance as a fringe benefit of employment. Soon unions used employer-sponsored health insurance as a bargaining chip in labor negotiations, and we all know the rest of the story. Health insurance is unique in this regard. After all, most employers don’t offer auto, home, or property insurance. The historical basis for this phenomenon, and our assumption that it is only humane and kind to make sure all of our citizens are protected for illness, have lead to the unintended consequences of waste, fraud, abuse, and price escalation. Soon it will also lead to rationing of care.

Although the Affordable Care Act of 2009 (ACA or Obama care) guarantees health insurance for all, it does nothing to increase the number of providers who will deliver these services. The approximately $750B of Medicare “cost savings” will be derived from reduced payments to hospitals and providers, making access to scarce providers even more difficult. A more complete critique of ACA, and its destructive effects on healthcare however, is subject for another blog.

So back to my car and health insurance. If I had been able to get a competitive price for damage repairs from several collision shops, I am sure that the insurance company could have saved money. Instead, they pay top dollar and pass it along to their customers. Similarly in my practice, there is no incentive to hold down the number of tests I order, since the prices are essentially fixed by Medicare, so that I, the provider, as well as the patient, the consumer, have absolutely no say in the matter. HMO’s, or the new ACA mandated Accountable Care Organizations, (ACO) are no better. Their incentives are every bit as perverse––just 180 degrees in the opposite direction. Fee-for-service, or traditional Medicare encourages too much testing and services that possibly cause improvement in the quality of care; whereas the HMO and ACO are incentivized to withhold care, and thereby increase their profits, again at uncertain damage to the patients’ health.

Free market and competitive solutions would help, but with the injection of the ACA as the law of the land now, I fear this will never happen, no matter who wins in November. As long as we view health insurance, rather than access to healthcare, as a right in this country, the problem will only get worse. But don’t believe me. Recently I cared for an elderly man from Great Brittan, who was hospitalized here for a heart problem. He was more than eager to share his thoughts about the British National Health system. After railing against it for several minutes, he summed it up with this, “You people are making a big mistake in this country.”

Older Posts »

Powered by WordPress