April 9th, 2009 by DrRob in Better Health Network, Quackery Exposed
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I got this in the mail today.
The spam filter didn’t work 100%. I know.
Why even post it? Just to comment on a society where people ask me “is it safe?” when I prescribe a medication for them and yet value the fact that people in Hollywood do something. Most of the people in Hollywood are idiots and are surrounded by more idiots.
Let me reassure you:
- Your body is not “full of toxins.” When it is, your liver and kidneys are designed to handle those “toxins” and will do so far better than anything someone tries to sell you.
- Diets only work when they restrict calories.
- Your colon is fine and does not deserve to be regularly “cleansed.” Colonics have been around since the early 1900’s (maybe earlier) and the fact that they are still being used is only evidence of the gullibility of humans.
- Never trust something that claims to “strengthen the immune system.” It is an impossible claim to prove or disprove, and so is made with impunity.
- Look for the word “supports.” Phrases such as “supports prostate health” or “supports a healthy immune system” are big signs that you are being BS’d.
- I never give patients medicines I would not take myself in the same circumstance. I know no doctors who do. It is fine to say “why do I need this medicine?” or “Is this medication really necessary?” but to ask “is it safe?” or “doesn’t this destroy the liver?” is kind of insulting.
- I guarantee that any plan like this one will cause significant weight loss…in your wallet.
Sorry. Had to rant about this. People believe many dumb things and will until the world’s end. I feel bad for the people brought in by this and am angered at the hucksters that are fattening their wallets and misleading the uninformed.
End of Rant
*This post was originally published at Musings of a Distractible Mind.*
March 31st, 2009 by DrRob in Better Health Network
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Our office has been on Electronic Medical Records (EMR) for nearly thirteen years. We see a high volume of patients, keep our overhead down, and are able to be quite successful financially. All of the “EMR is impossible” and “EMR makes things worse” stuff you read around the web are disproved quickly with a step into our office. We implemented EMR successfully in a private practice setting without help from an economic stimulus, a hospital system, or a magic wand.
Not that it was easy; we went through many years of struggle to get to where we are today. We struggled mainly because we were exploring unknown territory. We had very few other successful EMR implementations to learn from. We used slow computers and programming developed in the pre-Internet era. We made huge mistakes and struggled at times to make our monthly budget.
But we did it, and practices implementing now can learn from my and others’ success. Probably the main lesson we learned is to put office function ahead of implementation. Since we are a business, we must stay profitable while implementing. Since we are practicing medicine, we must never compromise quality in the process. This meant that we implemented over time, focusing on parts that would either improve our process or at least not bring us down.
Now we are at the position I thought might never come: survival is no longer in question, so we can dream. We don’t have to act defensively, we can push the envelope. We can afford to ask the question: “How can we build the best medical experience for our patients?” We can imagine a destination and actually attempt to get there.
The ideal destination is one in which our patients’ care is improved by maximizing efficiency on our end. Obviously I don’t want to make things harder for our practice, I want to make things easier. But the goal of care is ultimately centered on the patient, not us. So is there a way to accomplish both goals? I think there is, and I think that our EMR is the tool that makes it possible.
Here are our goals in the process:
- Simplify how things are done
- Always have the right information available
- Make communication clear and easy
- Achieve the highest quality possible
I’m sure some think this is just idealism and can’t happen in reality. I agree and disagree. No system can be perfect, but the current healthcare system is so inefficient and ineffective that huge gains can be made. The best way to show that is to get down to specifics. Here is where our practice is heading:
Simplify
The thing that takes the most time away from actual patient care is documentation. Doctors are paid by the volume of documentation, not its quality. Still, the main purpose of a record is to accurately know what is going on with the person facing you in the exam room. Unfortunately, the patient is continually changing, so some information is only accurate for a short time. Has the patient seen a specialist or been in the hospital? Have the medications been changed, or just not taken? Have they changed jobs, quit smoking, or gotten married? Did their sister just get diagnosed with cancer? The task of keeping this information up to date is extremely difficult.
Patients are the ones who know these things best, but they are only passive participants in the process. To keep the record accurate, I must ask them all the right questions on a regular basis. This cuts into time that should be devoted to care. So why can’t the patients be allowed to maintain this part of the record? Why shouldn’t they have access to parts of their record and the ability to correct errors? Here is how we see this happening:
- Certain parts of the record should be available for patients to review online. Basic demographics, medications and allergies, family history, and lifestyle information is a good start. If something new has happened, the patient can either update this information directly (like marital or smoking status) or notify the office of changes (like medication lists).
- If the patient doesn’t update it online, then they can do so when they come into the office (while sitting in the waiting room). Some people will undoubtedly not want to do this, but a significant percent will, decreasing the workload on the office while maximizing the quality of information.
- Patients should be able to communicate important information to the office online. If they go to the ER or see a specialist, if their blood pressure or sugars are high, they should be able to send that information directly to the physician.
Another area of potential gain is the gathering of information for a visit. When a person comes to the office, they have to answer a series of questions related to the visit:
- what are the symptoms the are having?
- Are there any other symptoms?
- How have they been since the last visit?
Gathering this information is essential, but it is one of the main causes of delays. Here is how we want to employ technology to improve this process:
- Put kiosks in our waiting room where patients can provide information, such as:
- History of their present illness. If they are sick, then what are the symptoms and how long have they gone on?
- Review of systems. What other things are going on in their health?
- Medication and demographic review (if not done already online).
- If patients fill out information online before coming to the office, the staff will bring them to see the doctor immediately (or at least as soon as possible).
Even 50% participation by patients in this process will have a huge impact on our office workflow. The end result is a win-win: the patient is seen sooner, the information is more accurate, and the workload of the staff is reduced. Will there be problems? There always are; but the advent of ATM machines, airport kiosks, and online shopping are a few examples of process automation that have greatly improved the customer experience. Why should medicine be different?
I am going to stop here, as I don’t want to lose you (if you haven’t already whacked the keyboard with your forehead). Hopefully you can see that the use of technology applied smartly can help patients and medical offices at the same time.
And this is just the start.
**This post was published originally at Musings of a Distractible Mind blog.**
March 9th, 2009 by DrRob in Better Health Network
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Healthcare is bizarre. Anyone who spends significant time in its ranks will attest to the many quirky and downright ludicrous things that go on all the time. But I am not sure people realize just how strange our system is. Perhaps it would be interesting to see what it would be like if other parts of our lives were like healthcare.
1. Get up in the Morning
The first thing that happens in your day is that your alarm fails to go off. Although you have major things happening, nobody ever has explained to you exactly what you are supposed to do and when. You watch the morning TV show and it seems that some experts say you should go to school while others say you should avoid school at all cost. You call a friend who says that she knows someone who went to school and it destroyed their liver. Another friend goes to school every day and is just fine.
Confused, you turn to the Internet and go to a website that explains that you should base your schedule on the pattern of tea leaves in a cup. This site claims that your normal schedule is actually fraught with secret appointments that will, unbeknown to you, make you have cancer. It states that those people in power are making you go through this dangerous schedule so they can make money off of you. They don’t care for you like the people who made this webpage (and for $400 you can have 6-months of magic tea leaves).
Finally, you decide that you are going to go with the majority opinion and go to school.
2. School
You go to your bus stop and wait. You keep waiting. You know that the bus was supposed to come at 8 AM, but after an hour you begin to wonder if you missed it. Calling the bus service, you find out that the bus got caught up doing some extra routes. There is a shortage of buses, and so the ones that remain have to do twice as many routes as is feasible. After a two hour wait, the bus finally arrives to take you to school.
The first teacher comes into the classroom and looks very distracted. She teaches general studies and is staring at a curriculum that contains a huge amount of subjects. As she is doing her lessons, she furiously takes notes on her own teaching so that she can submit documentation to the school board and prove that she taught you. This is the only way she gets paid.
In total, she teaches for about 15 minutes and documents her teaching for 45 minutes. You want to ask questions, but the bell rings and you have to move on to your next class before any can be answered.
The next teacher only teaches a small specialized subject. This teacher is paid four times more than the first teacher. Instead of teaching and answering questions, however, he is constantly making you take tests. Apparently, the school system pays a huge amount for making you take tests, but very little for teaching lessons that would make you do well on those tests in the first place.
School is finally over, but you don’t feel like you got much out of it (except for taking a lot of tests and getting more confused). You decide that a trip to the store would perhaps make you feel better.
3. The Grocery Store
Upon entering the grocery store, you notice something odd. There are very few different brands of items stocked on the shelves. Your choice is limited to only the brands that have struck the best deal with the grocery chain. These brands have to send the grocery store a large “rebate” check because they are carried exclusively in this store.
When you go to the meat counter and ask for some steak, the butcher asks you if you have first tried the ground beef. You may not purchase steak unless you have first tried and disliked the ground beef. The ground beef, of course, is actually ground turkey, but the butcher says that these two are basically interchangeable and so the substitution is permitted.
The grocer can’t post prices because all customers have different negotiated prices. Posting prices, in fact, would be considered collusion since other grocers could find out exactly what this grocer is charging. Some congressman in California decided that grocers are all crooks and should not be allowed to share what they charge for things.
You go to the cash register to pay. The total is $380, but the cashier informs you that your negotiated price is only $150. A poor person behind you has not had the chance to negotiate a price and so must pay full price for everything.
There are a few people in the store who don’t have to pay anything. They have had the price negotiated for them by the government, and so will come to the store very often. They sometimes come for real food, but are often coming for candy and cigarettes – all paid for by the government.
This experience leaves you more tired and confused, and so you decide to go home.
4. Home
Coming home, you notice that your house is under construction. There is a new wing being built that contains all sorts of the newest and fanciest gadgets, such as flat-screen TV’s, the fastest computers, and wonderful new kitchen appliances. Going into the house, you notice that there is no running water or heat. Apparently, there are all sorts of grants and low-interest loans to pay for the fancy gadgets, and so contractors find it much more profitable to do that instead of fixing water or heating.
Your mother is in the kitchen trying to make dinner, but instead of cooking she is staring into a cookbook and at the ingredients you brought from the grocery store. You assume she can make due with what you brought, but she just sighs helplessly. Despite the fact that your mother is incredible at improvising meals, she is required to follow a cookbook that doesn’t fit the ingredients that are available. This makes dinner taste pretty bad. Your mother, obviously angry about this, gives you a weak smile and tells you to finish what is on your plate.
After dinner, you settle down to watch some television. As you are finally starting to relax, a knock on the front door breaks your peace. At the front door stands a police officer. ”You are only authorized to be in the house for two hours today, so I am going to have to ask you to leave.”
You try to explain that two hours is not enough to get the rest you need, but the officer threatens a stiff fine and forces you to leave. Before you can get your necessary things, you are forced to leave – without an explanation of how you are supposed to survive on the streets.
(to be continued)
**This blog post originally appeared at Dr. Rob Lamberts’ blog, Musings of a Distractible Mind.**
February 10th, 2009 by Dr. Val Jones in Health Policy, Medblogger Shout Outs, Opinion
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Dr. Rob Lamberts does an admirable job explaining why physicians are worried about the Recovery Audit Contractor (RAC) approach to identifying Medicare fraud. Complying with Medicare coding and billing rules is so difficult that physicians regularly resort to undercharging for their services, just to avoid the perception of fraudulent practices. Any medical practice that bills more than average is potentially subject to RAC audit, and the auditors themselves are paid a commission for finding “fraud.” In many cases, the “fraud” amounts to insufficient documentation of appropriate and necessary work performed by the physician.
Dr. Rob writes:
The complexity of E/M coding makes it almost 100% likely that any given physician will have billing not consistent with documentation. Those who chronically undercoded (if they are still in business) are at less risk than those who coded properly. Every patient encounter requires that physicians go through an incredibly complex set of requirements to be paid, and physicians like myself have improved our coding level through the use of an EMR. This doesn’t necessarily imply we are over-documenting, it simply allows us to do the incredibly arduous task of complying with the rules necessary to be paid appropriately.
Have I ever willingly committed fraud? No.
Am I confident that I have complied with the nightmarish paperwork necessary to appropriately bill all of my visits? No way.
Am I scared? You bet. The RAC will find anything wrong with my coding that they can – they are paid more if they do.
Dr. James Hubbard writes:
It would be fine if they were truly looking for fraud and abuse, but they look for some technicality or just a different interpretation. Forget about any recourse. A few years ago, I was asked to pay Medicaid back $5000. I protested they were completely wrong with their interpretation of their findings. The auditors said I had to pay it, but could argue for a refund by sending forms and proof to the “review committee”. I did that and received a reply that the $5000 was too small for the review committee to take up. I stopped taking Medicaid.
Sounds like the Spanish Inquisition, doesn’t it?
***
For more excellent analysis of the subject, I strongly recommend Dr. Rich Fogoros’ recent book: Fixing American Healthcare.
December 7th, 2008 by Dr. Val Jones in Announcements, Medblogger Shout Outs
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Dr. Ramona Bates is a plastic surgeon who quilts. Dr. Rob Lamberts is a primary care physician who loves animals that begin with the letter “l” (such as lobsters and llamas). The two have put their creative minds together to benefit brain cancer – in honor of a fellow blogger whose young son is losing his battle with the disease.
This holiday season, you might consider bidding on Dr. Bates’ “lobster quilt” to support brain cancer research. There is a silent auction in progress here. Owning the quilt would make a good story, and the return on investment could be priceless. You can search for updates on the auction on Twitter: #lobsterquilt
P.S. Note that Dr. Rob has also started a traveling lobster initiative – where Zippy the plastic lobster is photographed by medical bloggers around the world to enhance awareness of brain cancer. I had the honor of hosting this little crustacean last summer, and took him to the White House. To learn more about Zippy’s travels, check out this website: http://funwithzippy.com/
