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Is The Increased Patient Safety Of The EMR Worth The Inefficiency?

With all the talk about how EMR/EHR resources will make practicing medicine better, faster and safer, I learned of an unintended consequence that is probably under appreciated these days. Hospitalists are being asked to admit more and more patients because, for primary care doctors, when they compare EMR medicine with the old way of  doing things, EMR is just too time consuming to make it worth their effort.

That’s right, hospitalists are admitting more patients because the primary care doctors find their time costs for navigating their new EMR, which they bought to qualify for EHR stimulus funds under ARRA, are simply too great.  In a business where efficiency must prevail, EHRs Read more »

*This blog post was originally published at The Happy Hospitalist*

The Not-So-New Problem Of Drug Shortages

Crucial drugs are running in short supply and patients are dying as a result.

Much of the problem stem from manufacturing problems that interrupt production. There may be only one or two companies making a drug, and when something happens such as contamination, it creates huge gaps. As a result, there’s been 213 drug shortages so far this year, or two more than all of the previous year.

The shortages have forced hospitals to resort to gray market purchases. These involved third parties that may corner the market on some drugs, and resell them at exorbitant mark-ups. The practice then fuels further shortages.

And this “new” crisis has been occurring for a decade. ACP Internist ran an article 10 years ago that could run in its pages today. Read more »

*This blog post was originally published at ACP Internist*

CDC Addresses Infection Transmission Through Organ Transplants

Over the past few years, my team at the CDC looked into more than 200 reports of unexpected disease transmission through organ transplantation. Of the cases that were confirmed, some had fatal outcomes. Clearly, transmission of infections through organ transplants remains a patient safety concern that calls for action.

To help address the problem, CDC recently led a team of experts to develop the Draft 2011 Public Health Service (PHS) Guideline for Reducing Transmission of HIV, HBV, and HCV through Solid Organ Transplantation. The guideline was posted to the Federal Register last week, and I encourage your review and comment.

While recognizing the critical need for organs, our team also wants Read more »

*This blog post was originally published at Safe Healthcare*

Minute Clinics Fill A Legitimate Need, But Are They A Good Idea?

All of us have been to fast food establishments. We go there because we are in a hurry and it’s cheap. We love the convenience. We expect that the quality of the cuisine will be several rungs lower than fine dining.

We now have a fast medicine option available to us. Across the country, there are over 1000 ‘minute-clinics’ that are being set up in pharmacies, supermarkets and other retail store chains. These clinics are staffed by nurse practitioners who have prescribing authority, under the loose oversight of a physician who is likely off sight. These nurses will see patients with simple medical issues and will adhere to strict guidelines so they will not treat beyond their medical knowledge. For example, if a man comes in clutching his chest and gasping, the nurse will know not to just give him some Rolaids and wish him well. At least, that’s the plan.

Primary care physicians are concerned over the metastases of ‘minute-clinics’ nationwide. Of course, they argue from a patient safety standpoint, but there are powerful parochial issues worrying physicians. They are losing business. They have a point that Read more »

*This blog post was originally published at MD Whistleblower*

Teen Poses As A Physician’s Assistant: How Did This Happen?

Did you hear about the 17 year old teen that posed as a physician assistant at a Florida hospital for five days and got away with it? Are you surprised? I’m not.

It seems that Matthew Scheidt, had a summer job working part-time for a surgical supply company. He allegedly went to the Human Resources Department of the Osceola Regional Medical Center (ORMC) and convinced them that he was a Physician Assistant student at Nova Southeastern University and lost his identification badge. This is the hospital where many of my former patients were forced to go for medical care because they were either uninsured or received Medicaid. My former employer had a fiscal relationship with them. The use of the word “forced” is quite appropriate because my uninsured patients had no options. Read more »

*This blog post was originally published at Dr. Linda Burke-Galloway*

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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