I’ve been distracted this summer, and this blog has
suffered.

My professional situation is evolving, happily for the
better, but I have been somewhat distracted by the negotiations required to
relocate my office, and establish new affiliations with not just one, but two
health care organizations.

All of this will lead to  new office space at John Heinz Institute of
Rehabilitation Medicine in Wilkes Barre and my involvement with sleep labs in our local Veteran’s Hospital, and one run by the Hazleton Health Alliance, in that city to our south.

I still have to physically move the office and still have a
lot of work going forward but I should be able to be more attentive to this
little project of mine.

I hope you’ll make it a point to check in from time to
time.

Here’s an editorial of mine, published in our Local Wilkes Barre Times Leader, discussing the pros and cons of the upcoming Federal regulation that requires your physician to record the details of your encounters electronically.

 

 

 

ONE OF the big changes recently in the practice of medicine is Medicare’s push for physician’s practices and hospitals to convert their documents from paper charts to an electronic medical record (EMR).

Starting in 2011, medical providers are given extra reimbursement by Medicare for adopting and using an EMR.

The mantra from advocates is that EMRs allow easy transfer of a patient’s medical information from caregiver to caregiver, avoid duplication of testing, decrease costs and reduce medical errors. Much of this is probably true. As a physician, however, I worry that EMRs as implemented can actually downgrade the quality of information passed between health care teams and at least, in some ways, increase the cost of care.

Now, I’m a computer-oriented guy. It irks me to see data collection in my office occur through the filing of printed, white cellulose sheets in green cardboard folders – a format with no digital access. I definitely want an EMR.

First problem is that they are rather expensive. The company that supplies my current billing software has offered to install one: for $35,000. For my solo private practice, that’s a lot of money.

Practices spend it, however, because of a benefit to them little talked about in public. Insurance companies, and particularly Medicare, have set up rather convoluted rules regulating physician reimbursement. To determine payment, insurance companies factor in the length of the encounter, the number of “bullet points” in the history, the completeness of the physical exam and the complexity of the “decision making.” The rules are complex. Most of us have a sense of them; but when seeing a patient, it is cumbersome to review the precise rules related to your encounter. Many doctors will guess at the correct billing code involved and, if anything, “under code” the insurance, for fear of fines if the practice is ever audited.

EMR companies buffer the “sticker shock” of a system with an important advantage. First, EMRs have the ability to increase one’s billing codes by documenting the actual complexity of an encounter.

In the long run, Medicare and other insurances judge your encounter by what’s recorded in the patient’s record. During his or her visit did you review your patient’s medications or their past medical history and/or social history? Most caregivers would, but don’t take the time to document it. Now, with a couple of mouse clicks, the data is drawn into the encounter note. Suddenly your documentation is brimming with “bullet points.” The software also can draw in recent lab data, radiologic results or any data available in the system digitally. A 10-minute encounter can look, in the record, as if you spent an hour with the patient. I’m not saying that providers are defrauding insurers, but I suspect the ease of documentation facilitated by an EMR certainly lets them “capture” all of the value for each patient visit.

Now here’s the really compelling part of the EMR sales pitch: Once the note is digitally recorded, the software can analyze your patient encounter and suggest the actual billing code. No more “under coding.” EMR vendors speak of $10,000 to $20,000 of income added to a practice’s bottom line per practitioner. In fairness, by the insurance company’s own rules, it is money owed to providers; but in this setting, the technology is definitely not decreasing costs.

In the case of large health care systems, all of the provider advantages are magnified. Plus, everyone in the system working with a patient has access to a single electronic chart with all the clinical data. I have access to a system such as this and it can be wonderful. The governments’ plan is that in the future all EMRs will be able to talk to each other in this fashion.

There are other problems, however. As EMRs proliferate, and increased Medicare scrutiny looms, medical documentation is evolving from its original goal of recording what actually was going on with a patient, and what the provider was actually thinking, to sterile boilerplate documents designed to justify the highest billing codes.

In years past, a well-written history and physical, or progress note, would unfold like a story, giving a vivid description of the patient’s symptoms and physical exam at the point of the encounter, as well as the synthesis of the data and the plan of care.

In an EMR an “H and P” is often reduced to random collections of data combined digitally with sterile prose that describes weakly, if at all, the clinical situation.

This problem occurs because most physicians don’t type fast enough to be efficient using an EMR. Because of this, they are prompted to use what EMR companies refer as “smart phrases,” pre-composed text designed for relevance in a broad range of circumstances. Dictation into the record is sometimes an option, but transcription is expensive.

So most electronic medical records tend to be full of data, but short on nuance. I currently dictate most of the notes in my office and hope that they convey my exact thoughts to my colleagues. I do worry that an EMR might degrade this.

Much of my inpatient work is at sub-acute facilities and involves accepting transfers from acute care hospitals. Because of this, I often have to review complex hospital records. Given the current technology, old-fashioned written notes, which tend to be brief but focused on the important details of care, are far easier to digest than their all-inclusive, and often repetitive, digital counterparts.

So how do we improve EMRs? First, I think we need to find a way to separate the documentation for billing’s sake, from that needed for patient care. These are supposed to be medical records for clinical use, not part of a contest between medical billers and insurance companies.

We need to provide a way for practitioners to document their exact thoughts in the electronic record in a cost-efficient way. This might happen as younger caregivers, who tend to type, come into the work force. I hope that improvement in speech-to-text software will be a solution for us more “established” physicians.

As I am hopefully in the middle of my career, I am extremely excited about the potential for this technology. I look forward to the efficiency and improvements in quality it might bring.

I just don’t want it to highjack my documentation for its own purposes.

 

Dr. Henry F. Smith Jr., a Fairview Township resident, practices pulmonary medicine in the Wilkes-Barre area.

I’ve been distracted of late.

Every ten years, I am required by the American Board of Medical Specialties to recertify in the  medical specialties in which I am Board Certified. For me this means Pulmonary Medicine , Sleep Medicine, and Critical Care, which occur on different cycles. I am currently in the final stages of study for the Pulmonary Exam, so the blog has been relatively quiet. I will have to take the Critical Care exam in November.

I am thrilled however with the continuing interest in the content that is currently available.

Once I’m done with the current exam (May 4th), I will have some breathing room.  I have several things I’d like to explore in writing here.

Until them, wish me luck.

 

 This is an Editorial from the fall 0f 2009 as published in the Wilkes Barre Times Leader, on a diagnosis , that from the veiwpoint of a Pulmonary/Critical Care/ Sleep physician, is starting to overwhelm medical services in the United States.

It was written for a local Northeastern Pennsylvania perspective, but I think it applies to most of the US if not the bulk of of the developed world.

Although it is often mentioned as a cause of rising health care costs, I’m not sure that the average person understands the true impact of the epidemic of obesity on the healthcare system.  The statistics on obesity are available and sobering; 2/3^rd of US adults are considered to be overweight.  33% of adults in the US are categorized as obese (Body mass index greater than 30 kg/m2), up from roughly 12% in 1962. Twenty years ago, when I started my practice, perhaps twice a year a patient would present that was too heavy for my 350 pound capacity scale. Now it would easily be twice a week; the scale in my office now accommodates 750 pound patients.  I have personally cared for folks as heavy as 650 pounds.

Our affluent society has given us extraordinary access to high caloric foods. Fast food makes up an increasing percentage of our diets, and purveyors, keep inventing larger and more caloric offerings to entice us.  Foods high in sugars and carbohydrates tend also to be the least expensive which partly explains why obesity rates in the US are higher among the poor.  People are often just not aware of what they’re eating. A dozen chicken wings can actually equal a person’s total recommended caloric intake for the day. “All you can eat” buffets encourage a pattern of eating that can be potentially lethal to the wrong person.

We also lack perspective. When all your friends weight around 300 pounds, it may not seem terribly alarming to be approaching 400. I encounter this denial issue all the time. We sometimes have to confront people with the extraordinary degree of their obesity problem. It is not uncommon to have to remind a patient that they are three times their ideal body weight. Young people can be the most difficult to convince. When you are young man, you can manage a 300-400lb body without too much trouble. It is only later in life that such patients will develop the respiratory, back, hip, and knee issues that can be devastating.

It is well recognized that obesity leads to increased rates of diabetes, heart disease, malignancy, arthritis, and other health issues. A problem that is specific to my specialty (Pulmonary and Sleep Medicine) in the obese patient is Obstructive Sleep Apnea, a condition where breathing is interrupted during sleep by collapse of the patient’s airway. Treatment usually requires the purchase of a CPAP device, a small ventilator that pressurizes a patient’s airway during sleep, preventing this. This is expensive technology.

More expensive yet are the power chair and “scooters” increasingly provided to those whose weight, along with the inevitable arthritis of the knees and hips, makes them unable to walk.

At their “end stage”, patients become essentially immobile, unable to walk because of the orthopedic and respiratory problems. And because of their extreme weight, and complex medical problems they are often not considered to be a candidate for elective surgery such as joint replacement, because of the multiple risks associated with surgery in this population.

The respiratory system is affected by obesity in other ways. First, excess weight is an additional inescapable burden that must be carried about, increasing symptoms in anyone with an impaired cardiopulmonary status. Obesity tends to increase the severity of Asthma by both mechanical and metabolic effects.

Some obese patients will develop Restrictive Chest Wall Syndrome, which occurs when excessive soft tissue envelops the chest and inhibits the patient from utilizing their total lung volumes. An extreme form of the latter problem is referred to as Obesity Hypoventilation Syndrome. Also called “Pickwickian Syndrome” (named for a character in the Dickens novel The Pickwick Papers), the condition is usually linked to Obstructive Sleep Apnea, and in  occurs when chest wall restriction is extreme, and the patient hypoventilates to a degree that they retain carbon dioxide in the bloodstream and can literally be “smothered” by their  own adipose tissue. They will often respond to positive pressure therapy at night (similar to CPAP), and of course, significant weight loss.

Obesity has profoundly altered healthcare in hospitals. The obesity epidemic has forced healthcare facilities to purchase new, so-called “big boy” beds, chairs, lifts, and other equipment to deal with the burgeoning dimensions of our patients. Nursing staff bear s much of the burden of the epidemic. It is increasingly difficult for a single 150 pound female nurse to provide care to patients who are often more than double her weight.

Simple procedures such as even intravenous lines become difficult. Procedures such as central venous lines are even more problematic. These larger intravenous lines, often used in emergency situations, are placed using anatomic landmarks for guidance. As those landmarks are obscured in the obese patient, ultrasound imaging is now often necessary for successful placement. Even more troubling is that at some point, patients can become too heavy to undergo diagnostic test such as CT scans, for fear of breaking the scanner’s gantry, which could delay care for other patients.

Recently at John Heinz, morbidly obese patients were noted to be an increasing percentage of our inpatient and outpatient Pulmonary Rehabilitation Programs. This prompted us to create a unique Bariatric Respiratory program, utilizing our resources in Physical, Occupational and Respiratory Therapy, Respiratory Nursing   Pool Therapy, and Dietetics. It is available to obese patients who have respiratory diagnoses such as those mentioned earlier in the article. Patients can be enrolled as inpatients, usually in transfer from an acute care hospital, or attend as outpatients. The program consists of special joint-sparing exercise training, education, occupational therapy and an intensive program of dietary counseling with the goal of improving the patients cardiovascular fitness, increasing muscle mass, and thus metabolic rate, and planning a diet for slow, healthy weight loss.

  At Mercy Special Care Hospital, a Long Term Acute Care Hospital in Nanticoke, Pennsylvania, we have run a successful  ventilator-weaning program for the last twelve years. There too, we have seen a  shift from patients with diagnoses such as Acute Lung Injury, or end stage lung diseases such as COPD, to increasing numbers of patients whose ventilator dependence is due to Obesity Hypoventilation Syndrome.  Over the last several years, we have had great success treating obese, ventilator dependent patients by using a rather simple protocol. We carefully control their caloric intake, using precise metabolic monitoring, and begin aggressive physical therapy to make these bedridden patients ambulatory once again. Generally, once they lose 15-20% of their body weight, and begin to walk, they can generally be liberated from the ventilator.  Once liberated, they can be transitioned to home, or to the programs at John Heinz.  Such patients, if they participate fully, can have literally life altering results.

If you are struggling with weight issues, there is help available. Besides the programs mentioned above, there are numerous resources on the web including sites such as Web MD and freedieting .com.  The latter site has a calculator to establish your Body Mass Index, a rough guide to determine the need for weight reduction. Your physician can arrange a consult with a dietician to help you plan an appropriate weight reduction diet. Commercial programs such as Weight Watchers, Jenny Craig, and Nutrasystem can be very successful for the right individual. Finally, bariatric surgery is increasingly seen as a useful tool, offering long term health benefits to properly chosen patient’s that undergo it.

If we are truly control health care costs in this country, then recognizing obesity as a serious epidemic and effectively addressing it will be an important component of the solution. Recognition and treatment of the problem for individual patients can help them avert their own personal health care crisis.

Sadly, after January 2010, Medicare, in their infinite wisdom, restructured reembursement for pulmonary rehabilitation to  only those patients who carry the diagnosis of Chronic Obstructive Pulmonary Disease (cigarette-related airways disease), essentially eliminating outpatient rehab for obesity-related respiratory problems.  We continue to try to find ways to help this burgeoning patient population.