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Just What The ER Needs – Fake Patients

This is one of the worst ideas I’ve heard of in a long time – “secret shoppers” in the ER (h/t KevinMD and Dr. Wes). In an attempt to assess hospital quality, patients with fake complaints are sent to the ER unannounced to see how they will be triaged and treated. In one case, a woman complained of stroke-like symptoms (headache, slurred speech, and difficulty moving the left side of her body). She underwent a head CT (which was normal) and then signed out of the hospital against medical advice.

Let me tell you why this “secret shopper” idea is so bad:

1. The woman was exposed to unnecessary brain radiation via the CT scan – this risk is acceptable if a patient’s life is in danger, but why would a normal person wish to be exposed to additional radiation? I smell a law suit in her future…

2. The woman’s triage experience could not possibly represent the average stroke patient experience because she could not replicate the signs of a stroke and (if she tried) any good ER doc or neurologist would know that she was faking. A patient faking the symptoms of a stroke would likely be treated differently than a patient with objective signs.

3. Wait times are dangerously high in ERs across the country. Bumping legitimate patients with “secret shoppers” is unethical and downright dangerous.

4. If hospital staff know that some of their patients will be fake, this could result in mistrust of symptoms or stories and a backlash against real patients who might be confused with secret shoppers.

The ER secret shopper movement was clearly conceived by people who don’t understand the complexity of healthcare, and are applying reductionist principles that will cause unanticipated consequences. Physical harm to the shoppers, longer wait times for real patients, further mistrust by the medical community, and inaccurate quality assessments are only the beginning. I hope the AMA voices their disapproval of this practice.

Quality is better assessed by an average of real patient experience, along with data comparing treatment protocols with medical records. Fake patients have no place in the ER.

What do you think?This post originally appeared on Dr. Val’s blog at

Dumb Healthcare Ideas Of The Week

I’ve collected a few reports from my fellow bloggers that perfectly exemplify healthcare improvement/payment strategies designed by committee.

A nonsensical quality assurance program in Britain, via GruntDoc:

Britain’s nurses are to be rated according to the levels of care and empathy they give to patients under government plans. Health Secretary Alan Johnson told the Guardian newspaper that he wants the performance of every nursing team in England to be scored.

But he ruled out rating individual nurses and also said it would not affect pay.

Ridiculous medical record documentation rules via the Happy Hospitalist:

The E&M rules of documentation state very clearly what type of information is required on follow up cognitive care visits. They state that you need to include things like character, onset, location, duration, what makes it better or worse, associated signs or symptoms.

This is all fine and dandy when you can quantify a complaint (like pain, rash, headache, or weakness). But what do you do when a chief complaint does not involve a qualitative or quantifiable entity? There are no E&M rules that allow exceptions to these circumstances. So you get the following garbage:

Chief Complaint: Hypercalcemia [too much calcium in the blood]

HPI: She presented with hypercalcemia. It is described as chronic, constant, and parathyroid. The symptom is gradual in onset. The symptom started during adulthood. The complaint is moderate. Significant medications include lithium. Important triggers include no known associated factors. The symptom is exacerbated by dehydration.

There is not a single piece of information in that excert that was clinically worth anything. In fact, it reads as if it is computer generated with key word insertion.

Character: Moderate (what does that mean?)

Onset: adult hood (what the hell)

Location: parathyroid (seriously?)

Duration: chronic and constant and gradual in onset.(what a bunch of garbage)

What makes it worse?: nothing and dehydration in the same paragraph, completely contradicting each other.

Imagine how much time was spent entering this worthless information. Not only asking them but entering them into the computer. Imagine multiplying this by 25 times a day. And you wonder why health care is so inefficient. Because we have to ask completely meaningless questions to get paid.

A new way to thwart physician compensation via the Physician Executive:

According to a June 11 CMS announcement, doctors will have to reconcile their NPI data with their IRS legal name data in order to get paid.

It is a befuddling regulation since, as an employed physician, 100% of my billings have gone to organizations that paid me a salary. Why check my provider identifier with my tax information? They don’t correlate. I can pretty much promise you that they never have and sometimes the discrepancies have been fairly substantial.

I am sure this will be a huge problem for docs in practice who bill under their name and get paid directly. Any discrepancy in any character in the field will ensure non-payment. This is not the kind of thing your laptop spell check will prevent. If this regulation is enforced to the letter, it will assure that services are provided free of charge.

I bet that this billing “error” can also be enforced as fraud and abuse, leading to criminal charges, financial penalties, and time in jail.

This post originally appeared on Dr. Val’s blog at

What Defines Quality Care and Who Can Afford It?

Interesting thoughts from The Happy Hospitalist:

How do you define quality care?…

If preventing 90% of in-hospital DVT’s with a medicine that cost $30 a day was quality, so be it.

What if you could prevent 99% of in hospital DVT’s with a medicine that cost $300 a day. Would the 90% be quality or the 99% be quality? What if it cost $3,000 a day to prevent 99.99% of in- hospital DVT’s?

Which effort would be considered quality? Who defines the cut off, and at what price?

Here’s what he has to say about Pay for Performance measures, and why they won’t add up to significant savings:

Unfortunately, the measures being undertaken for quality initiatives are, from my stand point, minuscule in terms of the overall potential cost savings to the system.

And the reason is simply, at least in my part of the medical physician spectrum, a very large chunk of health care expenditures comes in the form of evaluation, and not management…

In the medical profession, there exists a sense of universal freedom to order tests, xrays, labs, and procedures with a sense of unlimited funding. Somebody will pay for it. My patient sitting in front of me is the center of my attention and their needs supersede all other needs from a social/financial point of view of the nation…
Where are the government incentives for quality medicine in the evaluation of disease?
Where is your bonus payment for not ordering the heart cath?
For not ordering the CT Angiogram?
Where is your physician bonus payment for not ruling out a low probability DVT?
Or not ordering an EGD?
For choosing watchful waiting.
Where are your quality bonus payments for evaluation of illness?
They simply don’t exist. Because doing so would overtly ration the public and create a firestorm.

Is the storm coming nonetheless?This post originally appeared on Dr. Val’s blog at

Healthcare Red Tape Of The Week: PQRI

How has the Physician Quality Reporting Initiative (PQRI) been going? Some insights are offered from an internist in the trenches, (the only 1 of 20 physicians in his practice who was able to figure out how to comply with the PQRI rules), The Happy Hospitalist:

I found out today many docs may not have qualified because of the way the government PQRI computers crunched the data (imagine that). You see, if my quality indicator was for antiplatelet use in stroke, and I submitted to CMS stroke as the 4th ICD code, along with three comorbid conditions ( like DM, COPD, CAD), unless I submitted stroke as diagnosis #1, PQRI would reject my submission. So CMS accepts your E&M code with stroke listed as the 4th diagnosis to get paid, but when that claim makes it to the PQRI folks, because stroke was diagnosis #4 and not diagnosis#1, PQRI would reject the submission and doctors all over this country were dinged for not reporting on 80% of qualified patients…

I also found out that PQRI indicator #36 calls for rehab ordered for all “intracranial” hemorrhage. During my meeting today I found out that the only ICD codes linked to this quality indicator are “intracerebral” hemorrhage. Sub dural bleeds, which are intracranial, are excluded. So are subarachnoids. They have problems even defining what they are trying to measure.

Guaranteed Quality Medical Care: Fantasy or Reality?

I have witnessed various disappointing doctor-patient interactions over the years. Sometimes the doctor is insensitive, other times he or she doesn’t listen to the patient – and errors can result. Young physicians are more prone to inappropriate patient and family interactions when they are feeling inadequate and insecure. A fellow blogger describes just this kind of problem with a young pediatrics resident:

A meek lady with a white lab coat
walks in and just starts asking medical questions. So
my answer to her first question was “Who are you?” She apologized and
said she was the pediatrics resident and asked a bunch of questions
that didn’t seem to us to have much bearing on the situation at hand.
We asked about why my son was making unusual gasping breaths ever since
he woke up and she said it was because he was crying. We said that he
was making these breaths before he started crying. She then said it was
probably hiccups. My wife, who is a registered nurse, said there was no
way it was hiccups because she felt him pressed against her body and
could tell. The resident then said that it was probably due to the
anesthesia. I could tell she was just giving that answer to say
something but really had no clue what was going on. So I challenged her
on it and said “Have you ever seen this after anesthesia before?” She
paused and said, “Maybe once.”

Although this is not the wost example of an unsatisfying doctor-patient interaction (read the rest of the post to get the full story), it is pretty typical for inexperienced physicians to “make up” explanations for symptoms or problems that they don’t understand. This can be dangerous or even life threatening if certain symptoms are ignored.So how do we protect ourselves against this kind of potential error? Sadly, the current quality assurance programs are rather ineffective. In his recent blog post about ensuring physician quality, Dr. Scalpel published a letter he recently received from his hospital. The letter was prepared as part of the Joint Commission quality assurance program. They actually require doctors to get a letter of recommendation from someone (who doesn’t work with them) to ensure that they’re practicing good medicine… It’s like asking a stranger to grade your work competence.

Dear Dr. Scalpel:

accordance with Joint Commission regulations, we are required to
request an evaluation of your clinical performance. The Credentialing
Committee now requires the completion of an evaluation form by a peer in your specialty who is not a member of your group practice.

you will find a letter and accompanying evaluation form which you
should forward to a peer of your choice for completion. In order to
proceed with the processing of your reappointment application, it is
necessary that you ensure that the required evaluation form is
forwarded to a peer and returned to us in a timely manner. A return
envelope is provided for this purpose. Please note that the evaluation
form must be returned to us by the person completing the form. If we do
not receive the evaluation form before ________, your clinical
privileges may be interrupted.


An Unnamed Bureaucrat

So, how do you ensure that you’re getting good medical care? It’s not easy, and you can’t necessarily depend on oversight committees to come up with sensible safeguards. Being an informed patient is part of being an empowered patient – you should do what you can to research your doctor’s and hospital’s credentials and reputation (you can do that right here with Revolution Health’s ratings tool), you should read about your diagnosis or condition on reputable websites like Revolution Health, and you should advocate for yourself or loved one at the hospital when necessary. You have the right to reasonable explanations for care decisions – and if you’re concerned about a symptom, you should ask about it.

Unfortunately, there’s no way to guarantee quality medical care. However, perhaps the most important thing you can do (besides advocate for yourself and become educated about your condition) is to develop a close relationship with a primary care physician.  Establishing a medical home with a good primary care physician can go a long way towards helping you to navigate the system. They can be your best advocate in this broken system.This post originally appeared on Dr. Val’s blog at

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