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Medical Records in Primary Care: Keeping the Story of Phone Calls and Medication Changes with Less than Perfect Tools

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By HANS DUVEFELT, MD

I need the right information at the right time (and in a place that makes sense to me) to make safe medical decisions.

Here’s another Metamedicine story:

In learning my third EMR, I am again a little disappointed. I am again, still, finding it hard to document and retrieve the thread of my patient’s life and disease story. I think many EMRs were created for episodic, rather than continued medical care.

One thing that can make working with an EMR difficult is finding the chronology in office visits (seen for sore throat and started on an antibiotic), phone calls (starting to feel itchy, is it an allergic reaction?) and outside reports (emergency room visit for anaphylactic reaction).

I have never understood the logic of storing phone calls in a separate portion of the EMR, the way some systems do. In one of my systems, calls were listed separately by date without “headlines” like “?allergic reaction” in the case above.

In my new system, which I’m still learning, they seem to be stored in a bigger bucket for all kinds of “tasks” (refills, phone calls, orders and referrals made during office visits etc.)

Both these systems seem to give me the option of creating, in a more or less cumbersome way, “non-billable encounters” to document things like phone calls and ER visits, in chronological order, in the same part of the record as the office notes. That may be what IT people disparagingly call “workarounds”, but listen, I need the right information at the right time (and in a place that makes sense to me) to make safe medical decisions.

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Asinine, Backasswards Colonoscopy Insurance Rules Make Patients Decline Medically Necessary Testing

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By HANS DUVEFELT, MD

I’ve had several telephone calls in the last two weeks from a 40-year-old woman with abdominal pain and changed bowel habits. She obviously needs a colonoscopy, which is what I told her when I saw her.

If she needed an MRI to rule out a brain tumor I think she would accept that there would be co-pays or deductibles, because the seriousness of our concern for her symptoms would make her want the testing.

But because in the inscrutable wisdom of the Obama Affordable Care Act, it was decided that screening colonoscopies done on people with no symptoms whatsoever are a freebie, whereas colonoscopies done when patients have symptoms of colon cancer are subject to severe financial penalties.

So, because there’s so much talk about free screening colonoscopies, patients who have symptoms and need a diagnostic colonoscopy are often frustrated, confused and downright angry that they have to pay out-of-pocket to get what other people get for free when they don’t even represent a high risk for life-threatening disease.

But, a free screening colonoscopy turns into an expensive diagnostic one if it shows you have a polyp and the doctor does a biopsy – that’s how the law was written. If that polyp turns out to be benign, or hyperplastic, there is no increased cancer risk associated with it, but you still have to pay your part of a diagnostic colonoscopy bill because they found something.

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THCB Spotlights: Scott Shreeve, CEO of Crossover & Jay Parkinson, Founder of Sherpaa

Today on THCB Spotlights, Matthew chats with a couple of the OGs from the original days of Health 2.0—Scott Shreeve, founder and CEO of Crossover Health, and Jay Parkinson, founder of Sherpaa, who were the first ones doing something different in terms of doctors figuring out this digital health stuff. The two of them ask the question, what would happen if you married the physical world with the online world and created a new care model that exceeds at both? While Scott was putting in onsite primary care clinics to employers like Apple and Facebook, he realized Crossover wasn’t reaching 70% of the people they were contracted with because many employees were geographically remote. Meanwhile, Jay was doing something similar with virtual primary care—which differs from traditional telehealth in that his model enables a true relationship between patient and provider—and the rest is history.

“I Want Complete Labs Ordered Before My Physical”

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By HANS DUVEFELT, MD

Many patients make this or similar requests, especially in January it seems.

This phenomenon has its roots in two things. The first is the common misconception that random blood test abnormalities are more likely early warning signs of disease than statistical or biochemical aberrances and false alarms. The other is the perverse policy of many insurance companies to cover physicals and screening tests with zero copay but to apply deductibles and copays for people who need tests or services because they are sick.

It is crazy to financially penalize a person with chest pain for going to the emergency room and having it end up being acid reflux and not a heart attack while at the same time providing free blood counts, chemistry profiles and lipid tests every year for people without health problems or previous laboratory abnormalities.

A lot of people don’t know or remember that what we call normal is the range that 95% of healthy people fall within, and that goes for thyroid or blood sugar values, white blood cell counts, height and weight – anything you can measure. If a number falls outside the “normal” range you need to see if other parameters hint at the same possible diagnosis, because 5% of perfectly healthy people will have an abnormal result for any given test we order. So on a 20 item blood panel, you can pretty much expect to have one abnormal result even if you are perfectly healthy.

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Chronic Disease Drugs are Big Business, Antibiotics are Not

By HANS DUVEFELT, MD

I have noticed several articles describing how antibiotic development has bankrupted some pharmaceutical companies because there isn’t enough potential profit in a ten day course to treat multi-resistant superbug infections.

Chronic disease treatments, on the other hand, appear to be extremely profitable. A single month’s treatment with the newer diabetes drugs, COPD inhalers or blood thinners costs over $500, which means well over $50,000 over an effective ten year patent for each one of an ever increasing number of chronically ill patients.

Imagine if the same bureaucratic processes insurance companies have created for chronic disease drug coverage existed (I don’t know if they do) for acute prescriptions of superbug antibiotics: It’s Friday afternoon and a septic patient’s culture comes back indicating that the only drug that would work is an expensive one that requires a Prior Authorization. Patients would die and the insurance companies would be better off if time ran out in such bureaucratic battles for survival.

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Doctoring at Christmas

By HANS DUVEFELT, MD

I find myself thinking about how being a doctor has come to impact the Christmas Holiday for me over the years. I have written about working late and driving home in the snow and dark of Christmas Eve in northern Maine; I have shuffled Osler’s written words into something that speaks to physicians of our times; I have written about the angst around the Holidays I see in my addiction recovery patients.

This year, my thoughts go to the way Christmas is a time of reconnection for many people. We reconnect with family and friends we may not see as often as we would like, and many of us reconnect with secular traditions dating back to our childhood. Many people also reconnect more deeply with their Christian traditions, the ancient celebration of Hanukkah or the newer one of Kwanzaa.

As a doctor, I think Christmas is a time when individuals are more open toward others, more willing to extend “good will toward men” (Luke 2:14). It can be an opener for future relationships to form or grow, a time to share our humanity in the context of experiencing something larger than ourselves and our everyday existence. It allows us to get a little more personal by sharing something of what we all have in common – the need for togetherness with those we love.

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Thou Shalt Not Try to Outsmart Me

By HANS DUVEFELT, MD

Medical researchers and their groupies – early adopters, thoughtleaders, those easily influenced or whatever you want to call them – never seem to learn that when you try to outsmart Mother Nature or Our Heavenly Father, whichever appeals more to your world view, you usually get your hand slapped.

When I was a resident (1981-1984), I got penalized if I didn’t offer postmenopausal women estrogen-progesterone replacement therapy because it seemed obvious that if women with endogenous estrogen didn’t get many strokes or heart attacks and women without estrogen did, all we needed to do was make up for God’s or Mother Nature’s oversight in not keeping the estrogen coming after age 50.

Then the Women’s Health Study in 2000, almost 20 years later, showed that women on Prempro had more strokes, blood clots and heart attacks, and more breast cancer on top of that, than women who accepted the natural order of things – menopause with all its symptoms and inconveniences.

The same things has happened with osteoporosis – more subtrochanteric femur fractures after five years of Fosamax than in untreated women.

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The Public Health To-Do List is Choking Doctors and Jeopardizing Patients’ Lives

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By HANS DUVEFELT, MD

“By the way, Doc, why am I tired, what’s this lump and how do I get rid of my headaches?”

Every patient encounter is a potential deadly disease, disastrous outcome, or even a malpractice suit. As clinicians, we need to have our wits about us as we continually are asked to sort the wheat from the chaff when patients unload their concerns, big and small, on us during our fifteen minute visits.

But something is keeping us from listening to our patients with our full attention, and that something, in my opinion, is not doctor work but nurse work or even tasks for unlicensed staff: Our Public Health to-do list is choking us.

You don’t need a medical degree to encourage people to get flu and tetanus shots, Pap smears, breast, colon and lung cancer screening, to quit smoking, see their eye doctor or get some more blood pressure readings before your next appointment. But those are the pillars of individual medical providers’ performance ratings these days. We must admit that the only way you can get all that health maintenance done is through a team effort. Medical providers neither hire nor supervise their support staff, so where did the idea ever come from that this was an appropriate individual clinician performance measure?

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The Liability of Outside Provider Orders and What Could be Done About It

By HANS DUVEFELT, MD

As a family doctor I receive a lot of reports from emergency room visits, consultations and hospitalizations. Many such reports include a dozen or more blood tests, several x-rays and several prescriptions.

Ideally I would read all these reports in some detail and be more than casually familiar with what happens to my patients.

But how possible is it really to do a good job with that task?

How much time would I need to spend on this to do it well?

Is there any time at all set aside in the typical primary care provider’s schedule for this task?

I think the answers to these questions are obvious and discouraging, if not at least a little bit frightening.

10 years ago I wrote a post titled “If You Find It, You Own It” and that phrase constantly echoes in my mind. You would hope that an emergency room doctor who sees an incidental abnormal finding during a physical exam or in a lab or imaging report would either deal with it or reach out to someone else, like the primary care provider, to pass the baton – making sure the patient doesn’t get lost to followup.

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Playing Poker With the Devil: “Prior Authorizations” are Paralyzing Patients and Burning out Providers

By HANS DUVEFELT

The faxes keep coming in, sometimes several at a time. “Your (Medicare) patient has received a temporary supply, but the drug you prescribed is not on our formulary or the dose is exceeding our limits.”

Well, which is it? Nine times out of ten, the fax doesn’t say. They don’t explain what their dosage limits are. And if it isn’t a covered drug, the covered alternatives are usually not listed.

So the insurance company is hoping for one of a few possible reactions to their fax: The patient gives up, the doctor tries but fails in getting approval, or the doctor doesn’t even try. In either case, the insurance company doesn’t pay for the drug, keeps their premium and pays their CEO a bigger bonus.

First problem: This may be in regards to a medication that costs less than a medium sized pizza. And the pharmacy generally doesn’t even bother telling the patient what the cash price is.

Second problem: A primary care physician’s time is worth $7 per minute (we need to generate $300-400/hour). We could spend half an hour or all day on a prior authorization and there is absolutely zero reimbursement for it.

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