The Happy Hospitalist

Funniest Radiology Transcription (or Dictation) Mistake Ever!

2012-02-27T22:05:00.000-06:00

Saw this funny radiology transcription error the other day. Or maybe it was a dictation mistake. Or maybe it was intentional. Regardless, when the radiologist starts providing commentary on the status of your clinical picture, you know it's possibly time to throw in the towel. What was this funny radiology transcription report? It was from a chest xray and it said:

"right infiltrate has slightly, regrettably improved"

I'm think, just maybe, this patient was this radiologist's mother-in-law.

Here's another one of the funniest medical transcription errors I've seen.

Italian Greyhound Dogs in Action and Motion (Fun Pictures)

2012-02-27T21:13:00.001-06:00

Marty and Cooper, our little eight year old Italian greyhounds, went to the dog park the other day and I took a bunch of action pictures while they were in motion. I think I got some pretty neat shots. For all the dog lovers out there, I hope you enjoy them as much as I do.

View all our Marty and Cooper action (blog posts, videos and beautiful slideshow pictures)

Hawk Sitting on a Street Sign (Cool Picture!)

2012-02-27T20:37:00.002-06:00

I took this picture the other day of a hawk sitting on a street sign.Cool picture.

For your enjoyment, here's another picture I took recently of a hawk sitting on a street light and utility pole.

Silly Italian Greyhound Stands and Searches For Food In Baby Hi Chair

2012-02-27T08:57:00.000-06:00

Marty, our nearly eight year old Italian greyhound is convinced there is food in the baby hi chair. And he's not going to give up until he finds it. Another silly Marty moment.

Watch all of Marty's and his brother Cooper's blog posts, videos and beautiful slideshow pictures.

Planets Jupiter and Venus Converge with Moon February 26th, 2012 (Picture)

2012-02-26T21:53:00.004-06:00

Enjoy this picture I took of Jupiter, Venus and the moon all converging in a brilliant sky of light on the evening of February 26th, 2012. This picture was taken facing west at approximately 9 pm in the Midwest USA using my Canon T2i digital SLR. Read more about this phenomenon at earthsky.org.

Patient Satisfaction Survey Results May Be Influenced By Spelling Of Doctor's Name.

2012-02-25T20:39:00.003-06:00

It turns out you don't have to be a good doctor to get good scores on your patient satisfaction scores. You just have to have a name that is easily pronounceable. The name-pronunciation effect: Why people like Mr. Smith more than Mr. Colquhoun, published December 2011 by researchers Simon M. Laham, Peter Koval and Adam L. Alter in the Journal of Experimental Social Psychology suggests evidence for the name-pronunciation effect: easy-to-pronounce names (and their bearers) are judged more positively than difficult-to-pronounce names.

I am intrigued by this research as it has potential real life implications on how hospitals and their physicians get paid. The process that determines how hospitals get paid by Medicare has been turned upside down. Most recently, The Medicare National Bank has decided that patient satisfaction scores are so important they are going to withhold a percentage of hospital payments if defined patient satisfaction thresholds are not achieved.

Even though we know higher patient satisfaction scores are associated with higher mortality, hospitals are hiring experts in AIDET to teach their doctors and nurses how to be nice. This is an effort to prevent bloodshed and bankruptcy.

I don't think it's a stretch to suggest that patients would view physicians with easily pronounced names as more likable than physicians with difficult to pronounce names. The research here is very compelling. Do you have a difficult to pronounce African, Asian, Indian, Eastern European or Middle Eastern name? Your patients just might be discriminating against you when they fill out their patient satisfaction surveys.

If your hospitalist salary and compensation is tied to how well you do on your patient satisfaction surveys, and you have a difficult to spell name, I would work hard to exclude that component from your contract. This research might suggest your patients just don't find you that likable by no fault of your own. This makes me wonder if doctors with harder to pronounce names get sued more often or lose more often at trial. Perhaps this is the doctors' discrimination version of the death penalty.

What about all the nurses and other hospital employees that come in contact with patients? If patients have a higher likability for people with easier to pronounce names, will hospitals hire candidates with simple names in an effort to maximize results on their patient satisfaction surveys? Will inner city hospitals with a higher proportion of ethnic employees suffer needlessly at the hands of racial diversity?

I think this research suggests the patient satisfaction survey payment program being administered by HCAHPS is a potentially a racist program. If hospitals are going to get paid based on the "whiteness" of their faculty's names, hospitals may find reasons to avoid hospital physician credentialing to foreign born doctors or avoid hiring nurses that weren't born down the street. That's sad.

Read more about the name-pronunciation effect

Point-And-Click-EMR Carpal Tunnel Syndrome Strikes Again

2012-02-23T15:25:00.000-06:00

Point-and-click-EMR carpal tunnel syndrome is alive and well. Point-and-click-EMR carpal tunnel syndrome is a real and growing disabling condition striking thousands of physicians all across this country. I have seen a rapid expansion, over my last decade of hospitalist work, of the point-and-click office documentation EHR notes that read like broken English.

These EHR clinical notes are structured and populated in ways that offer limited insight into actual patient care but excel in the medical billing and coding aspect of evaluation and management documentation. Often, these notes say nothing of clinical relevance but meet all the criteria of a high level preoperative CPT® 99223 history and physical. These point-and-click notes maximize revenue at the expense of patient communication. Someone has to pay for these government mandated EMR data mining systems. Right?

Compare EMRs from any vendor and you'll find most of them will meet all the government approved specifications to get federal money but few are offered as great tools for doctors to communicate their findings to other physicians. You can find the best solutions out there with my free EHR guides. Most of these point-and-click EHR distractions actually hinder the ability of doctors to communicate pertinent findings with other physicians because the pages of worthless information they produce, for even minimally complicated visits, makes finding relevant information nearly impossible.

Enter the point-and-click EMR carparl tunnel syndrome. The American Carpal Tunnel Syndrome Society (ACTSS) has recently reported on a remarkable increase in physicians seeking surgical options for CTS. They discovered that point-and-click EMR systems were to blame for the rapid rise in physician disability claims.

I concur. Just the other day, I found this outpatient preoperative history and physical for a physician going under the knife.

CC: Pre-operative evaluation for CTSR

HPI: Patient complains of right hand numbness. This is the right hand. This is a follow-up visit for hand numbness for hand problems for hand weakness. He describes the intensity of weakness as moderate. Associated symptoms include numbness and weakness and patient has failed conservative therapy and has considerable disability due to the hand.

Just one real life example of how your doctors are communicating with your surgeons. This is not the future of health care in America. This is the current reality. Someday, all your physicians are going to be disabled from their point-and-click EMR CTS. And when that day comes, I just have to wonder, who is going to click in the blanks?

Nursing Home Services Include Stat EKGs? Define Stat!

2012-02-22T19:34:00.004-06:00

This cracks me up. I saw a nursing home marketing sheet the other day that explained the large variety of nursing home services being offered. Perhaps, it was this nursing home's attempt to separate themselves from the dozens of other local homes. Perhaps it was their way of trying to explain why they were better than all the rest.

Here's a screen shot of their list of nursing home services. They claim to offer stat EKG service in the nursing home. Stat EKG in a nursing home? That sounds great! But when you read the not so fine print you'll find that the nursing home definition of stat is much different than the hospitalist definition of stat.

What do you think about a stat EKG or Xray defined as 4-6 hours? That seems like a long time to wait, especially if you happen to be having chest pain or can't walk from your broken hip. It seems to me the word "stat" should be universally reserved for immediate action.

Can you imagine the uproar that would occur by the medical staff in a hospital setting if physicians ordered stat EKGs and xrays and had to wait 4-6 hours for the result?

I think this nursing home definition of stat explains a lot. The stat EKG gets ordered by phone at 10 am but doesn't get completed until 4 pm. By the time they hunt down the physician, or more likely NP, and by the time they figure out how to get the result faxed, the patient is either dead or deteriorating rapidly. It is no wonder why these folks always show up on the hospitalist night shift at 2 am.

Something tells me that if anyone at a nursing home is thinking about ordering an xray or EKG stat, and they are prepared for a 4-6 hour window for getting the test done, they will always default to the safest path of least liability and that is to go to the emergency room. That is how you get a stat test done in this country.

For more great nursing home insight from The Happy Hospitalist, visit:

What does SNF mean?
Nursing homes gone wild!
Barriers to palliative and hospice care: The Nursing Home.
What is a semiprivate room at a nursing home?
The stat nursing home consult!
Drunkest nursing home patient ever!
Admitting Diagnosis: To Old To Go Home
Nursing homes are scared of getting sued.
Does Medicare pay for ambulance transfer to the nursing home?
Nursing home exercise? Fencing in full gear!

Intravenous Nausea Medication Shortage Strikes Hospitals: At Least There's An App For That.

2012-02-21T19:06:00.000-06:00

I learned today that there is a nationwide shoratage of three of the top (and generic) medications used to treat nausea in this country. IV Compazine (prochlorperazine) has been on the unobtainable list for months and months. I recently learned that IV Reglan (metoclopramide) and now IV Zofran (ondansetrone) have joined to the ranks of the nearly impossible to obtain intravenous nausea medications in the hospital.

We've read alot in the last year about nationwide drug shortages. It's not just rare and expensive drugs. It's these generics that have been around for decades.

What's left? We can give IV Phenergan (promethazine), which is plentifully available. Unfortunately, due to a lawsuit in the not so recent past, it can now only be given with central venous access to prevent doctors and hospitals from getting sued out of existence. That pretty much made this medication unavailable to the masses of nauseated patients all across this country.

What's left? You can give some of them IM (intra-muscular) or you can give them orally, which is often difficult in patients who are throwing up or have nothing by mouth status after their surgery.

Add to that the nationwide shortage of intravenous Ativan and Versed and one has to wonder how hospitals can even stay open when such vital medications, standard of care in many circumstances, aren't available to treat patients.

If you are in the medical profession, and you have a smart phone (I speak for the iPhone since I don't have an Android), you can download a free app that will give you a list of current drug shortages, resolved shortages and unavailable drugs reported by the American Society of Health-System Pharmacists (AHSP) and the Food and Drug Administration (FDA). This ingenious app even has an RSS feed to daily updates,

Search for this free app with the search term "rxshortages" and you'll find it. I've never seen so many drug shortages in my nearly ten years of hospitalist medicine. It is concerning to say the least. I'm sure the reasons are complicated, but probably involved a combination of drug company consolidation and government regulations. The patient's don't care why. I think, unfortunately, it's only going to get worse as ObamaCare works hard to take the profit out of medicine.

Happy Ten Month Birthday Baby Zachary (My Little Tweetheart!)

2012-02-21T11:39:00.002-06:00

Happy birthday. Crawling. Wall walking. Opening cabinets. And talking back already. What do you have for us next?

See all of Zachary's adventures with all his blog posts, videos and slideshows.

Beer On The Hospital Formulary? This Bud's For You! (Picture)

2012-02-20T14:55:00.004-06:00

The only time I see buds in the hospital setting are on cultures with budding yeast. In this case, however, a reader sent me a picture of a single beer being cart delivered to a patient. Beer on the hospital formulary? Heck yeah. Why not? Sometimes beer can be the best therapeutic medicine we give to patients.

As a resident, I once had a VA patient request a Sports Illustrated swimsuit issue. It was the greatest gift I could give to a dying man, besides the right to death with dignity. Drink up my hospital friends. This Bud's for you! You don't even need a beer can, pop can, fake sleeve!

The only questions I have are what does a hospital charge for a single beer. Probably enough to cause a heart attack.

Medicare Demonstration Projects For Care Coordination and Value-Based Payments Fail To Reduce Cost

2012-02-19T13:22:00.001-06:00

Straight from the Congressional Budget Office comes a startling admission of less than stellar results for what was to become the new and improved Medicare National Bank. Medicare demonstration projects over the last two decades were out to prove once and for all that improved care coordination and disease management along with value-based purchasing would be the saving Grace for CMS and their promised smorgasbord of FREE=MORE. Unfortunately, on average, in these 34 Medicare Demonstration Projects, care coordination and value-based payment demonstrations failed to reduce costs. Straight from the CBO Director's Blog:

On average, the 34 programs had little or no effect on hospital admissions. There was considerable variation in the estimated effects among programs, however (see figure below).
In nearly every program, spending was either unchanged or increased relative to the spending that would have occurred in the absence of the program, when the fees paid to the participating organizations were considered.
Programs in which care managers had substantial direct interaction with physicians and significant in-person interaction with patients were more likely to reduce Medicare spending than other programs. But, on average, even those programs did not achieve enough savings to offset their fees.

Effects of 34 Disease Management and Care Coordination Programs on Hospital Admissions

(Percentage Change in Hospital Admissions)

The only successful program was the bundled payment for heart bypass surgery, which realized an overall costs savings of 10%, and even that savings, according to the report, may be overstated.

As I've said all along, the only way to reduce cost in Medicare is simply to stop paying for it. CMS can either stop paying hospitals and physicians (which they are through an assortment of unreasonable hoops, threats and retrospective theft of services), they can reduce benefits for Medicare beneficiaries (which will never happen) or the government can raise taxes and beneficiary premiums (which will never solve the problem and only delay the inevitable). Everything else you hear in the news is just noise.

CMS is the single largest threat to our National Security and nobody wants to you know just how painful fixing it will be. Look at Greece today , able to survive only on borrowed time and borrowed money, until their debts came due. CMS is Greece. Eventually, investors funding our retirees' unmanaged expectations are going to want their money back, with interest. When that day comes, and it will, it's going to be a very painful experience for everyone.

Death With Dignity Quote That Helped Family and the Power of Palliative Care.

2012-02-18T07:01:00.002-06:00

I received a nice Facebook comment from a long time reader about a piece I wrote several years ago about the right to die with dignity. Read on.

Just wanted to let you know, I had saved one of your blogs on death with dignity from 2009. It struck me then as logical and kind. My siblings and I just dealt with the death of my mother. Mild dementia, and DM and was slowing down at 76. It was painful to watch. She fell and fractured an ankle in Nov. It went downhill quickly after that, UTI after UTI ( I hate routing catheter placement btw) until it led to sepsis and acute kidney failure.

With her condition worsening and her dementia taking a drastic upturn, we decided enough was enough when dialysis was offered. Comfort measures only, hospice care, no more torture. It was a horrible decision that I never thought I would have to make. It is much easier to recommend it to patients, but I have a new empathy being on this side of the fence.

I made it to Fl on a Saturday, we laughed, talked a bit, made the decision. She died, in peace, the following Thursday. It was heart wrenching .Did we make the right decision? Going thru my timeline, I saw I had saved that blog to my notes and re-read it. It was true then and true now. Death with dignity. I have written about it for ethics class, but now I have experienced it in my own family. More needs said on this subject. My sister, who was also feeling guilty at 'pulling the plug' also got some comfort from reading this.

I must thank you. For the past few weeks since it happened, I have had guilt over what I know I would have wanted for me had I been in the same condition. This is, by far, the most comforting sentence, "we all know that by offering them everything, we are in fact giving them nothing". I'm glad I kept this piece. Just wanted to let you know that you do help.

Thank you for your kind words and I am grateful my words were able to help. I have been Graced with an excellent palliative care team in my daily practice. Palliative care is about the only patient centered specialty we have. A lot of what we recommend for patients, we do so out of our own experience and curiosity. In palliative care, the patient is the center of the universe. This process really is about defining goals and expectations and helping patients and physician team members understand our limitations. We know the palliative philosophy can dramatically improve the patient and family experience during the process of decline. Telling patients "no" is part of my responsibility as a physician. Sometimes physicians need to be told the same during the end of life palliative care process.

I'm glad your mother is at peace. You did the right thing. I have no doubt in my mind. You pulled the plug on her misery and sprung her free. Who wouldn't want that?

UPDATE: Read this shocking breaking story about an RN in Arizona, Amanda Trujillo, who was disciplined for providing a patient with the informed portion of the consent process. Go read the allegations as they relate to this story. They are disturbing to say the least.

Coding Challenges From Today's Hospitalist (Facebook)

2012-02-17T16:49:00.000-06:00

If you like to challenge your evaluation and management coding abilities, it's time to join the Facebook account of the journal Today's Hospitalist and partake in their coding challenges. Below is a screenshot for their current coding challenge (click on the picture below to take you directly to this coding challenge). It appears you have to agree to an "app" within Facebook. I did. It looks harmless to me.

I left my answer and rationale on this third installment of their coding challenge series. Leave your answer and a comment as well. I'd love to hear what you think.

Paging Protocols For Hospitalists: New Quiet Time Policy!

2012-02-17T09:34:00.002-06:00

I am proud to be part of a ground breaking method to improve hospitalist satisfaction with the introduction of a radically new paging protocol for hospitalists. Despite knowing that higher patient satisfaction scores increases mortality, hospital payment methodology is increasingly being tied to patient satisfaction and less on a patient's plan of action.

Smart hospitals understand this. They realize that, in today's payment environment, if they want happy patients, they have to have happy hospitalists. My ten year N=1 covert research study confirms a high correlation between patient satisfaction and hospitalist satisfaction. And my important research suggests the most important variable to improve hospitalist satisfaction is to minimize daily interruption of work flow by implementing strict paging protocols for hospitalists.

Smart hospitals are actually taking the lead. For them to get paid, they need to have a fleet of happy hospitalists. So it came as no surprise for me to learn that my own hospital is leading the pack with a ground breaking initiative intended to minimize hospitalist workflow interruption and to improve hospitalist satisfaction.

I saw this sign posted on the entry to a patient unit.

This is the new paging protocol for hospitalists. What does this mean for doctor-nurse communication? It means, except under grave circumstances, hospitalists will no longer accept pages between the hours of 1pm and 2 pm. This is their quiet time. It is their time of healing. I knew our administrators were amazing, but this is over the top! Hallelujah!

My covert inside sources tell me that if this paging protocol for hospitalists is successful, pending completion of the one week, single unit trial, hospital wide implementation will begin with expanded hours (1pm -12pm). Us hospitalists have agreed to sacrifice our lunch hour to be available for pages. Now that's what I call groundbreaking policy!

Baby Eats Italian Greyhound Dog Tail (Cute Video)!

2012-02-16T21:07:00.001-06:00

I took this video today of our almost ten month old Zachary discovering our seven year old Italian greyhound's tail. That's patient Cooper getting his tail tasted. The look on Zachary's face is just classic.

Not quite like a popsicle is it Zach? It's a cute video all around. Our puppies really do get along very well with Zachary. Soft and gentle, we tell him. Soft and gentle.

You can see all our blog posts, videos and beautiful slideshow pictures of our baby Zachary and puppy Angels Marty and Cooper.

Higher Patient Satisfaction Scores Associated With Higher Mortality and Increased Hospitalization.

2012-02-15T13:52:00.002-06:00

The Medicare National Bank is on a rampage to make sure their beneficiaries are happy with the care they receive. So much so, in fact, that patient satisfaction scores administered through the HCAHPS programs will determine whether hospitals lose millions of dollars a year in funding if they can't meet defined thresholds of patient satisfaction.

This is a radical change in hospital payment methodology. It means sex after joint replacement education is the number one priority in hospital care. It means the Slow Code Commission recommendations rule the day. It means in hospital fires, administrators are required to abandon all patients in favor of saving their manual on How to Win The HCAHPS Game. In today's payment environment, if hospitals can't make their patients satisfied, they can't get paid. And a hospital that doesn't get paid becomes irrelevant, just like those closed Hawaiian hospitals.

What is a hospital to do? Of course, they do what all hospitals must do in this situation. They hire nice experts to teach their doctors and nurses how to make their patients happy. For some hospitals, that means a healthy dose of AIDET.

But why? We aren't experts in happiness. We treat disease all day long. For many patients, happiness is achieved with awesome chiropractic marketing at trade shows and State Fairs, not at hospitals undergoing chemo for their metastatic colon cancer.

When did making patients happy become the number one priority for physicians and nurses? When did it become a hospital's mission to be more concerned about being nice than being good? It became this way when it became an issue of money. Should we be nice to patients? Of course we should be. Being nice is to be human. But I fear that creating an environment were being nice to get paid will cause our patients to suffer needlessly at the hands of over utilization of resources.

You see, many patients believe that more care is better care. They see the magic of technology and believe, foolishly, that every disease has a quick cure or every question has an answer that lies in a magic pill or magic intervention.

We know that the risk of dying decreases during a recession. Fascinating. When Israeli doctors went on strike several years ago, the nation's mortality rate actually decreased. Even more fascinating! Perhaps people do better because they fail to realize just how dangerous being in the hospital really is. Whether we're talking about dangerous hospital food trays, falling wall mounted IV poles, doctors using cell phones contaminated with poop, or living amongst the highly contaminated hospital privacy curtains, many patients fail to appreciate the dangers lurking all around them in the hospital setting.

And a recent study published in the Archives of Internal Medicine suggests just that. What was their conclusion? In a sample of over 50,000 patients, higher patient satisfaction scores was associated with a higher mortality, higher rate of hospitalization and higher overall resource utilization.

Wow. The Medicare National Bank, through the HCAHPS program, plans to punish hospitals that don't get the best patient satisfaction scores, when in fact, these patients experience the highest resource utilization and are dying at a higher rate than less satisfied patients.

This is concerning. As a physician, I have a hard time trying to provide care I know works and avoiding care I know doesn't when my expectations and the patient's expectations don't always coincide. While fully explaining why every pill or every intervention may or may not be indicated might help strengthen patient satisfaction scores, providing such an intensity of communication takes more time than CMS is willing to pay for, especially in the woefully inadequate evaluation and management payment model. Many physicians will simply bend to patient wishes, in the interest of high satisfaction scores, than to go through the highly time consuming process of informed consent. The authors agree.

This research suggests that CMS will punish hospitals that provide the best mortality outcomes, an unintended consequence of good intentions. As a physician, I have great concerns about being graded on my patient satisfaction scores if we have compelling data that suggests the nicer I am, the worse off my patients' outcomes.

If we want our patients to give us good satisfaction scores, perhaps hospitals should provide a free parting gift of sorts as a thank you for their business. Everyone likes FREE. Let the physicians and nurses stand strong to provide the right care, not the care that makes people give good happiness scores.

Go read the article in full: The Cost of Satisfaction. A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality It offers fascinating insight into how your care is being graded and how your satisfaction with those around is going to affect your own outcomes.

The Skeptical Scalpel agrees.

Why I Love My Wife: (A Special Valentine's Day Picture)

2012-02-14T13:21:00.001-06:00

Why I Love My Wife On Valentine's Day:

Spouse Etiquette In The Hospital: Use The Happy Hospitalist As Your Guide!

2012-02-14T12:37:00.001-06:00

The reach of Happy's blog is far and wide including learning the correct spouse etiquette in the hospital setting. I received this email from a reader a while back that I'd like to share:

Hi Happy, I wanted to let you know that you have a fan at Massachusetts General Hospital. My husband fell and hit his head a few weeks ago. He seemed fine after the fall. About 2 weeks after the fall, he started having weird symptoms with his balance so we went to the ED. He had a brain bleed and was transferred to Mass General. 2 surgeries later to drain the blood, he seems to be fine. He was in the neuro ICU for a few days after the surgeries. The first day a doc popped in and introduced himself as a Neuro Hospitalist. He went over who he was and what his responsibility was for my husband's care. I asked him if he was "Happy". He cracked up and said he reads your blog. We talked about your cute baby and dogs.

I loved having a hospitalist. If we didn't have him, I would have had to get to the hospital at 5 am if I wanted to speak to a doctor. Living 2 hours away made that difficult. The hospitalist was around all day. My husband said that there was another one that was around all night.

I didn't know that hospitalists could have specialties like Neuro. I appreciate that I knew what a hospitalist does via your blog. I also feel like I knew "patient's spouse etiquette" because of your blog. I kept myself together on the outside even though I was screaming and crying on the inside.

Now we just have to get through the recovery period without me killing him.

Thanks,

No. Thank you. It's letters like this that make my day. I hope their neuro-hospitalist, if they have been reading anything of substance at The Happy Hospitalist, provided you with a phenomenal AIDET experience to help get you through the anxiety of your husband's acute illness, but, more importantly, so that you gave them really high patient satisfaction scores.

More and more these days, many medical and surgical specialties are introducing their own hospitalist concept. In addition to neuro-hospitalists, OB-hospitalists and surgical-hospitalists are a growing trend. And to some degree, the "hospitalist" concept has already been introduced into many medical specialties already, where some doctors do a week at a time of exclusive hospital work before switching with their partners back into their outpatient clinical responsibilities.

This is why, if you are admitted to a hospital, you will rarely get to see your normal cardiologist or gastroenterologist or nephrologist, or even surgeon. It's because all the docs cross cover for each other these days. It's rare to be a patient that can see their own regular physician from start to finish. It just doesn't happen anymore. I'm sure, eventually, a dividing line will be made between exclusive inpatient and outpatient care. Medical care will be fragmented into only hospital or only outpatient care. Just give it time.

From a "patient's spouse etiquette" standpoint, morning hours are the best time to be present if you want to personally talk to the physician. The later in the day you arrive, the more likely you are to request to talk to a cross covering physician.

I can speak, from personal experience, cross covering doctors are available to "put out fires" and to address critical issues that may arise from time to time. We are not the right doctors to speak with if you want accurate information on the care plan of our loved one. Often times, the cross covering physician may not be in the hospital or may be too busy admitting ER patients to provide bedside consultation on cross covering patients.

While many hospitalist groups can provide 24 hour in hospital cross covering care, that care should be appropriately limited to acute care issues that require rapid bedside evaluation and the cross covering physician should not be involved in the day to day housekeeping issues and family discussions that should happen during routine daily hospital rounds.

Hope all is well with your husband..

Can Doctors Sue Patients For Noncompliance?

2012-02-10T11:55:00.002-06:00

A reader poses a question: Can I as a physician sue a patient who is non-compliant as his non-compliant actions leads to readmission within 30 days time and again?

The simple answer to the question is anyone can sue anyone for any reason. Whether you will win the lawsuit or not is another question entirely. I don't think you would win. I don't even think a basis for your lawsuit exists.

I presume you pose the question as it relates to the heart failure 30 day readmission rules that are about to stop paying hospitals for the care they provide on patients readmitted within the 30 days for a principle discharge diagnosis of heart failure, acute myocardial infarction or pneumonia. I'm not sure suing patients is going to reduce the readmission rate.

All hospitals and physicians have options. If we don't want to play by the rules being established by the Medicare National Bank, we all have the option of opting out of this program. If we don't like the rules, we don't have to play by the rules. If you find yourself dependent on Medicare money, either you play by the rules or you work hard to find alternative revenue streams and get out.

Medicare is undergoing a major change. Again. The program is not sustainable by any reasonable yardstick. Our elected political leaders are forcing all the changes onto the backs of hospitals and doctors under the erroneous assumption that we are to blame for hospital readmissions. All the noise about increasing quality is just that. Noise.

The reason we can't afford to provide the care we are promising these days is because we have brainwashed the public and our government officials into believing we can provide more care than we actually can. A great part of what we do in chronic disease management offers no longterm therapeutic value. We provide short term bridges to the next hospital readmission. Medicare has graciously defined what our goal should be. Our treatment bridge is now 30 days. Why? Because that's the economic reality they have defined for us.

As doctors, we help navigate a chronic disease out of the acute phase. However, we cannot make a failed liver work again. We cannot make end stage COPD patients breath normal again. We cannot make a nearly dead heart beat again. Beyond the diagnostic portion of our medial practice, successful management of chronic disease is much less a medical issue than it is a social issue. If we want to prevent hospital readmissions, we have to reengineer our society, not punish our hospitals and doctors. It's just easier to blame hospitals and doctors than to blame all the rules and regulations won by special interest groups that got us here.

The simple and easy fix is to stop paying hospitals. The only people who are going to suffer when their inner city hospital closes due to a lose of millions of dollars in funding are the medically complicated poor inner city patients. You could almost consider the no payment for hospital readmissions policy racially biased.

Hospital profit margins are already in the negative. That's not going to stop patients from being noncompliant. It won't make them take their medications. It won't make them go to their doctor visits. It won't make them better understand the limits of what we can do for them. In fact, it might even make access to care more difficult. It won't give them transportation to get to their doctors' visits. It won't make them stop drinking or smoking or eating fast food. Nope. When we stop paying hospitals for readmissions, we will simply reduce their ability to provide care to these poor folks.

Even though we live in the age of technology, biology will always win. Call it God's Victory if you will. In the era of shock television where glorified technology can fix everything and unmanaged patient expectations rule the day, our patients are staying alive longer, often under miserable circumstances, because we can make it happen. When Medicare finally implodes, and it will, things are going to get really ugly. How quickly that happens depends entirely on how quickly we are able to get control of our spending crises in this country.

Readmissions are going to be a part of life for the hospitalist. In fact, as a hospitalist, I know many of my patients are readmitted multiple times in a year. That's because biology always wins. For whatever reason, CMS has chosen 30 days as the magic number to avoid payment for services provided. Hospitals will do everything in their power to get patients to this thirty day window.

And then stop. Hospitals simply don't have the resources to reengineer society. Their goal is to get paid.

There is no medical basis to the 30 day window. This is a cost containment program. It isn't about quality or value based purchasing or accountable care organizations or whatever the message of the day is. It's about not paying for care provided. Would these people survive in a country that did not have the promise of unlimited access to all health care all the time. Not a chance.

If we want to avoid readmissions, putting the burden on hospitals to make it happen doesn't make sense. Hospitals and physicians are in the business of treating disease. Treating disease is expensive, especially given the enormous regulatory burdens we practice in. We know that 5% of our population spends 50% of our health care dollars. Hospitals will formulate programs to keep their frequent fliers out of the wards for thirty days. These folks will then get readmitted on day 31 and it isn't going to save CMS a dime. It will just make hospitals that fail to play the game correctly shut down even faster. Hawaiian hospitals closed down recently. And it's only going to get worse.

If Medicare wants to save money, CMS has to admit that hospitals and doctors are not to blame. We have two generations of failed social engineering policies sponsored by special interests and imposed on us by a Congress that only looks to the next election for answers. If we want to reduce readmissions (past the magic 30 day window), we have to reduce chronic disease. This process will take decades and a complete reengineering of society.

Or, we could try suing our patients and see how far that gets us.

Baby's First Day Sledding (Race Car Sled Video!)

2012-02-09T15:32:00.000-06:00

We had our first major snowstorm of the year and nine month old Zachary finally got to experience his first day sledding. Here he is in this video with his brand new turbo charged race car sled. He had a blast. He only crashed three times!

See all of Zachary's blog posts, videos and pictures.

Italian Greyhound Loves Rolling In Sheepskin Rug (Video Fun)!

2012-02-09T15:17:00.003-06:00

Marty, our eight year old Italian greyhound, loves our sheepskin rug. He loves rolling in it. He loves digging in it. He loves eating it. He loves eating it so much, that we can't leave him unattended with this sheepskin rug. I think it must be smell.

Enjoy the Iggy video!

See all of Marty's and Cooper blog posts, videos and beautiful pictures.

Hospitalist vs Internist (Outpatient Office Based Clinic)? Top Ten Reasons To Choose Hospitalist

2012-02-08T21:51:00.011-06:00

If you are an internal medicine resident, considering whether to enter an office practice or a hospitalist practice, pay close attention to this information before you make your decision.

I've put together my top ten list on reasons why you should pick being a hospitalist over being a clinic based outpatient internist. These ten advantages are based on my nearly decade long experience as a practicing community hospitalist at a major regional referral hospital system.

#10. You'll never have to do another pelvic exam ever again. Refer back to PCP or if a patient of yours is sick enough to require an emergency inpatient pelvic exam on your hospitalist service, then it's time to consult the gynecologist. Besides, after a couple months of hospital work, you'll forget how to do them. Yeah. That's it. Pelvic exams are outside your scope of practice.

#9. Chronic abdominal pain does not meet inpatient criteria. Nor does chronic headache or chronic dizziness or the chronic state of refusing to leave the ER. Tell the patient their insurance won't cover the hospital stay because it won't. Then, discharge the patient from the ER and refer back to PCP. Oh, and if by chance they come in on observation status, after 48 hours, their chronic problems won't get paid for either. Tell the patient that, then refer back to the PCP. The most you'll have to deal with chronic anything is 48 hours.

#8. Refer patients requesting you fill out paperwork for a motorized electric mobility scooter back to their PCP. You're just not trained for that.

#7. Nor are you qualified to fill out their disability paperwork. Everyone in the hospital is disabled. Your patient needs the keen eye of their outpatient doctor making unbiased determinations as to whether their fibromyalgia, headaches, chronic back pain, having too many kids or not having enough motivation qualifies them for disability. Refer back to PCP.

#6. Fax pharmacy refill requests back to the pharmacy with the notation "send to PCP". Or not. Eventually, the patient will figure out why they aren't getting their medication and call their PCP or just not care enough to fill it.

#5. Social workers. Having social workers available for hospital disposition is like swimming in a pot of gold at the end of the rainbow. Good social workers are magical in their abilities to perform near miracles. On the other hand, bad social workers will wreak havoc on your day. Overall though, social workers are a victory for hospitalists. You aren't going to have social workers at your disposal in your office practice. They're called secretaries. And they are too busy putting hosptialists on hold who are trying to update the PCP on their patient's discharge.

#4. No more calls from nursing homes. Nothing will break your spirit as an internist more than getting calls from nurses in nursing homes regarding, well, just about anything. As a hospitalist, the closest you'll ever come to talking to a nursing home nurse is, well, I take that back. You'll never have to talk to a nursing home nurse again. Don't get me wrong. Nursing home nurses are nice. They just don't share the same medical vocabulary as hospital based medical professionals.

#3 Our frequent fliers already have 12 fully transcribed H&Ps in the last year. It doesn't get any easier than that. The vast majority of our patient's have a rather high level of continuity that few non-hospitalists can appreciate. We aren't strangers to our patients. We know many of them very well. We aren't starting from scratch when we see them for the first time. This month. We are reviewing, copying and pasting just like the rest of the EMR world does.

#2 We get paid to sleep on the job. As a physician hospitalist, you simply aren't required to report to any superior if you want to take a break and catch a few hours of sleep during a difficult night shift so you can prepare your mind for the next critical care admit that may roll in any second. Sleep or don't sleep. It's up to you. Try sleeping during your office practice with patients piled up in the waiting room. Your nurses will quit on you.

And the #1 reason to choose hospitalist over outpatient office based clinic internist is, on discharge, we get to write "follow up with PCP within a week". It fills the hospitalist with a peace and tranquility that only the hospitalist psyche can fully appreciate. We hold this feeling dear to our hearts. I only wish all physicians could experience the same.

Explain CPT® and ICD Codes. What is the Difference?

2012-02-06T18:01:00.003-06:00

I get a lot of questions from readers, especially physicians, who have no idea what CPT® codes and ICD codes are. If you don't know what CPT® and ICD codes are or what they are used for, then you've just found the best five minute explanation out there.

CPT® stands for Current Procedural Terminology. CPT® codes are owned by the American Medical Association. They are a series of numbers (usually five digits long) that are used to identify medical services and procedures performed by physicians as well as diagnostic services. They are a language of communication with third party insurance payers.

ICD stands for International Statistical Classification of Diseases and Related Health Problems. As the name implies, ICD assigns a number to describe thousands of possible diseases, as well as traumatic, social and environmental circumstances leading to bodily harm. These codes are a giant data mining operation.

ICD is published by the World Health Organization. Currently the United States uses version ICD-9. Version ICD-10 promises to expand the nomenclature of disease states by ten fold (as well as the associated headaches), using an expanded series of digital identifying characteristic. ICD-10 should go live some time in 2013, unless it's pushed back, again.

Evaluation and Management (E/M) describes the series of CPT® codes that don't involve any type of procedure, but rather physician time, intensity of service and complexity of the evaluation. I have written a series of free hospital based evaluation and management lectures. E/M includes office visits, hospital visits, ER visits, nursing home visits and so on. These codes usually begin with the digits 99xxx.

You can get your CPT® manual here:

Physicians are paid by insurance companies (including the Medicare National Bank), based on what CPT® code they submit. In order to submit a CPT® code, the physician must attach ICD codes along with the CPT® claim. There must be a reason for the visit (the ICD code). Insurance companies don't want to pay physicians for a visit that involved nothing more than discussing Super Bowl baby pictures.

What is the reason for the visit? Is it chest pain? Is it hypertension? Is it pre operative evaluation for surgery? Is it for a painful leg? Is it to follow-up diabetes? What is the reason for the visit?

There must be an ICD code for every medical encounter, whether it is getting a CT scan, doing a colonoscopy, performing a thyroidectomy or visiting the doctor in the office. When a physician submits their CPT® code to insurance companies, they must attach ICD codes as part of their documentation. As a hospitalist, if I see a patient for a stroke, to a third party insurance payer I would submit ICD code 434.91 (cerebral artery occlusion, unspecified with cerebral infarction) attached to a CPT® code. The CPT® code I choose would depend on what type of E/M service I provide.

If I was admitting a patient to the hospital, I could choose critical care E/M CPT® code 99291. If my visit lasted longer than 74 minutes, I could also submit the add on critical care code 99292. If I didn't believe my visit met the level of critical care, I could submit hospital admit codes 99221, 99222 or 99223 depending on what level of care my documentation supported. If I was seeing the patient as a hospital follow-up visit, I could submit CPT® codes 99231, 99232 or 99233 depending on what my documentation supported. If I saw the patient as an consultant in the hospital, I could choose CPT® codes 99253, 99254 or 99255. On discharge from the hospital, I could submit CPT® code 99238 or 99239, if my visit lasted less than or equal to 30 minutes or more than 30 minutes respectively.

In every circumstance, whatever CPT® code I submit for payment, I must attach at least one ICD code to support the reason for the encounter.

In addition, certain ICD codes are being used in combination with certain CPT® codes to create the monstrosity of a program, called the Physician Quality Reporting System (known as PQRS for 2010, previously known as PQRI). Currently an optional program, PQRS promises to penalize doctors in the near future (witholding a percentage of payment) for not appropriately submitting the right CPT® code with the right ICD code.

There, now that wasn't so hard, was it? It might help this reader answer their own question that was submitted last month:

I am nurse practitioner in outpatient. I have a high end electronic (Littmann 3200- with sofware analysis) stethoscope capable of recording heart sounds, sending via infrared to a PC for further analysiss of cardiac murmurs to determine if the murmur is benign or refer to cardiology. It provides a hard copy of heart sound analysis for the chart. When we use this code, do we receive a separate reimbursement or does it support a more detailed physical? What is the reimbursement?

Thanks

2012 ICD-9-CM Diagnosis Code 785.2
Undiagnosed cardiac murmurs
ICD-9-CM 785.2 is a billable medical code that can be used to specify a diagnosis on a reimbursement claim.

As indicated, ICD code 785.2 represents the code for undiagnosed cardiac murmers. You attach this ICD code to your CPT® code of your visit, defined by the type of visit and site of visit (hospital, clinic, nursing home, consult, established, follow-up and so on.).

As far as I know, there is no billable CPT® procedural code that can be used with an electronic stethoscope above and beyond the basic stethoscope with a human computer brain between the ear pieces. If there was, I would be submitting my hospitalist E/M codes with a 25 modifier to get paid extra for listening to my patients' hearts and lungs for the last 10 years.

As far as supporting a more detailed physical exam, 1997 CMS guidelines provide the following bullet points used to define the extent of the cardiovascular exam:

Palpation of heart (eg, location, size, thrills)
Auscultation of heart with notation of abnormal sounds and murmurs
Examination of:

carotid arteries (eg, pulse amplitude, bruits)
abdominal aorta (eg, size, bruits)
femoral arteries (eg, pulse amplitude, bruits)
pedal pulses (eg, pulse amplitude)
extremities for edema and/or varicosities

1995 CMS guidelines do not provide detailed exam components.

So, in answer to your question, I am fairly certain that you can't bill a separate CPT® procedural code in addition to your E/M code for the encounter. I am pretty sure placing a fancy computer generated print out of your electronic stethoscope's murmur interpretation provides no additional physical exam complexity or additional bullet points.

Despite the complexity of your question, I am intrigued by your practice style of using an electronic stethoscope to determine if a murmur is benign or if it needs to be referred to a consulting cardiologist. A cardiologist? Perhaps the first place to start, as a primary care trained provider, is to send the patient to the patient's pediatrician, family medicine doctor or internist or, if you are being sponsored by one, to get their opinion first. These doctors are capable of providing a higher level of care than can be interpreted by a computerized stethoscope and are very useful in avoiding unnecessary subspecialty consultations. If you have a sponsoring physician that condones this practice, if I was a patient in that practice, I would get up and walk out and tell everyone I know to avoid the doctor that needs a computer to listen to you. If you are practicing independently without a sponsoring physician, I might suggest you not. You're going to get yourself into trouble real fast.

I've just gotta ask, what do the cardiologists on the receiving end of your abnormal stethoscope read out consults think? I can't even imagine the laughter going on at the cocktail parties. This is some of the finest cardiology humor ever.

Cardiologist #1: Remember that patient that coded 12 times on the table? It shocked the heck out of me!
Cardiologist #2: That's nothing. I have a nurse practitioner that sends me ten consults a week based on an abnormal computerized stethoscope read out.
Cardiologist #1: No way. That's tops 'em all. I need to find me one of them folks.

Quite frankly, I'm shocked that this kind of practice style exists. Does this stethoscope also provide a detailed printout of breath sounds for referral to a pulmonologist if necessary? Will it recommend a gastrenterology consult if the bowel sounds are a bit off too? How about an electronic tendon hammer that can tell use if the reflexes need a neurologist to evaluate. Maybe my next major purchase should be an ophthalmoscope or otoscope that can give me right answers to my physical exam. A pen light with a digital read out? Now we're talkin'. How about computerized physical exam gloves that can detect an enlarged liver or spleen edge. Makes sense to me.

On second thought, since we have vein light technology and pupillometers, nothing like this should surprise me anymore.

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Italian Greyhound Scared of Heat Vent Video (Squeaker Fun!)

2012-02-06T08:48:00.000-06:00

Cooper, our almost eight year old Italian greyhound hates heat vents. He is so scared of them that even grabbing his favorite squeaker, ele the elephant, from on top of the heat vent is a chore. Cute Iggy fun!

Watch all of Marty's and Cooper's blog posts, videos and beautiful picture slideshows.