Tag Archives: electronic medical record

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Fraud in medicine: why “help” won’t help

This article:  Doctors wasting over two thirds of their time doing paperwork showed up on Facebook yesterday.

The problem is that “hiring people to help with paperwork” will not help.

Why? We’ve already done that and it’s a huge mess.

For example: I was referred to an Ear Nose and Throat Specialist at one of the Seattle Mecca hospitals. I had to travel two hours and then in the waiting room I was given a four page patient history to fill out. I filled it out. I had been referred by a Neurologist, who sent a letter and note. After I filled out the forms, HIPAA and “you will pay if your stupid insurance won’t” and address and consent to be treated and yada yada…. I waited.

At last I was shown to a very luxurious room. There a medical assistant asked me many of the same questions that I’d filled out on the form and which were already in the letter and note from the neurologist. She typed these into the EMR- electronic medical record. Then she left. And I waited.

At last the distinguished otolaryngologist entered the room. He said, “I see that you are here for chronic sinus infections.”

“No.” I said. “I am not.”

Silence.

“I see that you did not read anything I filled out and I am a physician and I drove two hours to see you.”

Silence. “Um.” he said. “Uh, why are you here?”

“Strep A sepsis twice and we want to know if my tonsils should be removed.”

Right. So… all that paper you fill out before the physician saw you? Yeah, like, my impression is that physicians don’t read it until after you leave. And maybe mostly don’t EVER read it.

I plan to find out the next time I have to see a specialist. I will write “you don’t read this anyhow, so I am not filling this shit out” on page 2 and see if the specialist notices. Bet you money they don’t. Though when they yell at their staff for not entering my medication allergies or the review of systems, they might notice.

So… I am a primary care physician. What do I do?

A new patient has one form: name, address, insurance information, hipaa and “you pay if your insurance doesn’t”.

I do the health history myself in the room entering it in the first visit, which takes 45 minutes to an hour. WHOA! INEFFICIENT! Nope. Actually it is brutally efficient. For four reasons:

One — I enter it myself and ask the questions myself and I am really fast at it.

Two — now I know the person, because I went over all of it: complaint, history of present illness, past medical history, social history, allergies, review of systems, and I ask people to bring all their pills including supplements to the first visit and I enter them too. And I look at the bottles. I don’t like vitamins with 6667% of the Recommended Dietary Allowance of any vitamin, lots of vitamins now have herbs in them too and I would not recommend taking cow thymus, labeled as bovine thymus.

Three — Now I don’t have to spend time reading forms filled out in the waiting room or a history entered by someone else, because I don’t have time to do that anyhow. I did it all in the visit. I will still have to read old records and any labs or xray results or consult notes or pathology reports and hey, where do you think the waiting room paperwork falls in that priority list? Yeah, like never.

Four — I hand people a copy of the note as they leave and ask them to read it and to bring corrections if I got it wrong. They go from thinking that I am a drone staring at the laptop to saying, “Hey, she typed nearly everything I said (and she has three spelling errors).”

Because the truth is that medicine is really complicated now and it just doesn’t help to have more people “do the paperwork”. I have to read the notes and labs and reports myself, because I am the physician.

There are three things that WOULD help:

1. One set of rules. Hello, the insurance companies, all 500ish of them send us postcards and emails every week saying “Hey, we’ve changed what we cover, meaning we cover less and we have new improved and more complicated prior authorization rules! Go to our website to read all about it.” Guess how often I have time to do that. NEVER NEVER NEVER. I read medicare’s rules. So medicare for all, single payer is partly to have ONE SET OF RULES. I can memorize miles of rules, but not if they are changing in 500 companies every week. Shell game. Also, prior authorization means “your insurance company is making your doctor fill out paperwork in hopes that they can delay or refuse the care your doctor thinks is best for you.”

2. One electronic medical record. Right now there are about 500 of them too and none of them talk to each other so we are all “paperless”. Ha. It’s worse than ever, because we get 100 pages or 200 or 300 of printed out electronic medical record for every single new patient. I need two more big file cabinets for my “paperless” office. Hong Kong did it in 9 months. What, are we wimps? Make a decision.

3. Standardization of lab and xray and home health and physical therapy and nursing home and rehab and hospital order forms. Because every stupid lab form is different: not only arranged differently but also the lab panels are different, the requirements for what that lab wants to fill the order is different and the results are arranged differently on the page. Hello. Stupid, right? Any efficiency expert would laugh.

And that’s how we could really help doctors help patients.

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Fraud in medicine: FAXMANIA!!

All right, the latest trend in the complete insanity that is the United States Medical Corporate Black Hole Eating The American Dream: FAXMANIA!!!!

I am a Veterans Choice rural provider. Well, I thought I was. But turns out even though the VA keeps calling me to accept new veterans who are more than 40 miles from the nearest VA, they have not paid me for one visit in 2015. And I did between 20 and 30.

Because, you see, even though they have me listed as a Veterans Choice Provider, the paper work is SPECIAL and it has to be PERFECT and we have to fax EVERYTHING.

So I have to fax every single clinic note to Veterans Choice. Where, presumably, they lose it and have plausible deniability. Also, when a patient comes to see me, they are only approved for ONE NEW PATIENT VISIT, TWO FOLLOW UP VISITS, WITHIN THE STATED DATES, which is two months. Then I have to fill out a form and send it to Veterans Choice, who sends it to triwest, to get approval to continue to be my patient’s primary care doctor FOR ONE YEAR ONLY. Then I have to remember to do it again. AND I have to fill out a form to send to Veterans Choice, who sends it to triwest, for every single referral or test more complicated (read: expensive) than an xray AND for labwork AND don’t forget to fax a copy of every clinic note to Veterans Choice so they know I did it AND now for one patient’s medicine, I have ALSO fax a copy of every note to his VA PRIMARY CARE DOCTOR so that she will refill his pain medicine because: Hell if I know, apparently it’s EASIER to fill from her than me because the VA has no frigging idea who I am.

And the Veterans Choice 40 mile rule? We have two patients now from Whidby Island. They have to take a ferry to see me. Yes, they can bring a car on the ferry. Yes, they can get here except when the ferry is canceled for very low tides or weather….Yes, it’s insane.

Meanwhile, this note from the State of Washington Health Care Authority, aka medicaid: “The Contractor shall require that when subcontracted provider organizations with certified EHRs see an Apple Health Managed Care enrollee, they send a care summary (CCDA) from the providers EHR to the WA Link4Health Clinical Data Repository beginning no later than February 1, 2017.” Translation? Oh, we have to send bloody proof that we saw the bloody patient in the form of a CCDA electronically OR ELSE! OR ELSE WE ARE BREAKING THE LAW! They wouldn’t want to fire us but you betcha they would love to fine the hell out of us. Note: This requirement only applies to provider organizations who have already invested in certified EHR technology.

Hi, Big Brother.

Now, fax is HIPAA compliant, as long as we include the cover disclaimer that IF WE SENT IT TO THE WRONG PLACE SHRED WITHOUT READING OR YOU WILL BE STRUCK DEAD BY LIGHTENING FROM THE SKY GODS AND/OR THE ORBITING LASER HIPAA POLICE.

And meanwhile I have lab order forms for the three labs in town (all completely different and even with different panels) and one in Sequim, also 6 different forms for 6 different places for xrays, CT scans, MRIs, a form for the Vascular imaging, a form for cardiology, different ones for each physical therapy office. Now the DMV disabled parking form must be accompanied by a prescription on legal Washington State prescription paper saying yeah, he is disabled. Why use one piece of paper when you can require two?

When I fill out lab orders for the local hospital, the patients sometimes say, “Can you fax that over?”

“Yes,” I say, “but they lose 50% of them.” No, really. We fax them and keep a copy and then the patient goes in and the lab calls and says, “We don’t have the order.” I am not sure if they are “lost” or just in a pile to be entered into the TIME SAVING ELECTRONIC MEDICAL RECORD COMPUTER SYSTEM THAT MAKES EVERYTHING FASTER AND MADE US PAPERLESS EXCEPT FOR THE TEN MILLION FAXES DAILY. “You are better off picking it up and handing it to them, or I can mail it to you.” The other day a patient asked if that was malice, since I am not in the hospital system. “No,” I said, “I think they have laid people off until there aren’t enough and the corporation dumps the long timers that know stuff and cost more.”

Once I was working on a holiday Monday. I had a patient who I thought had a new arrythmia. I called the hospital and asked the tech if we could do an outpatient ECG on this holiday.

“I don’t know.” the tech said.

There was a silence. I wondered if the tech would ask someone in authority.

“I’m new.” said the tech. “They’ve laid a lot of people off.”

Someone in authority WAS present. “We can do one on a holiday.” I said firmly. “I will send her right over. Call me when it’s done.” So the tech did it.

Where medicaid goes, medicare follows and then the insurance companies will too. Next, I predict that we will have to fax every note to the appropriate company every single visit, and to the secondary insurance too. And then they will install a video camera in each office and videotape every clinic visit…. and I will either be a physician in another country or be doing something else….

 

What, you say, does the shack have to do with this? I can always go live there, off the grid, if I can’t stand the paperwork and hoops I have to jump through. It is a play house at my family’s land on a lake in Ontario, built in the 1970s. Friends and I put a new roof on this year: their 6 year old was delighted. It would be frightfully cold in the winter and anyhow, I can only stand straight in the middle….