Follow up Meaningful Use Stage 3 is coming

Yesterday, I posted "Meaningful Use Stage 3 Is Coming: Should Be Fun" which discussed some onerous new rules that Stage 3 will impose including this one:

More than 25% of patients seen by an eligible professional (EP) or discharged from a hospital or emergency department (ED) must "actively engage" with their electronic health records (EHRs).

I said that in my experience most of the patients I took care of would have been unlikely to engage their EHRs and expressed concern that physicians would be penalized for their patients not reaching the 25% threshold.

A reader commented that the VA has had a patient portal called the Blue Button since 2010. He pointed out that in May of 2012, more than 500,000 unique patients had accessed their EMR. He meant this as a rebuttal to my opinion about the potential level of engagement.

However, it turns out that in 2012 over 6.3 million patients were treated by the VA system.  [See page 4 of this link.] If you divide 1 million by 6.3 million, you get 15.9%.

It seems like they have quite a way to go to get to 25%

I rest my case.

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Iatrogenic polyuria

Dr. William Reichert commented on a recent post of mine. I thought he told an interesting story and with his permission, I am featuring it here so more of you might see it.

He wrote

Some time ago, I was consulted on a patient because of excessive urination. The patent was putting out 4 or 5 five liters a day and nobody knew why. I checked out all the usual suspects, diabetic ketoacidosis, hyperglycemia, diabetes insipidus, etc. and all the medications listed on his chart. No diuretics. Finally, at my wit’s end, I entered the ICU room and noticed a number of med bags, some full, some empty hanging there on the IV pole. I checked each and discovered a bag labeled "dopamine” slowly dripping in.

I went to the nurse and asked how long the patient had been on dopamine. She said "Hes not on dopamine." I said, "Come with me" and showed her that he was in fact getting low dose dopamine, a drug that behaves like a diuretic.

Unbeknownst to those "taking care" of him, he had been on dopamine for no one knows how long. The next day I got a call from the head of nursing informing me that it was not nursings fault. Perhaps the IV team or the pharmacy was responsible. I agreed with her. I did not want to be accused of being mean to the nurses. Anyway, according to the computer printout and the nursing notes, he was NOT on dopamine. Maybe a relative sneaked in and hung the drug. No one was faulted. The problem resolved. No "root cause analysis” was undertaken. Why bother?

This reminded me of a polyuria story of my own. One weekend, I was covering for another surgeon and rounded on a postop patient whose urine output had been increasing over the last several days. The labs were OK, and he had no obvious reason for his 3500-4000 mL/day outputs. I looked at the intake and output records [this occurred back in the day when such things could easily be found at the bedside] and saw that he was getting more and more IV fluid every day. I called a resident and asked him what was going on. He told me they had been increasing the IV fluid rate every day to keep up with the losses in the urine.

Facepalm!

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Problems with surgical residents and continuity of care

How are we doing with residency training and continuity of care? Not too well if you believe a recent paper called "Continuity of Care in General Surgery Resident Education" appearing online in the American Journal of Surgery.

A group from Rush University in Chicago looked at the records of 228 patients who underwent commonly performed operations during the year 2012. They found that in only 21/228 (9.2%) of cases had the operating resident seen the patient preoperatively, and in 20/223 (9.0%) had the operating resident seen the patient in postoperative follow-up. In no case, did the operating resident see the same patient both pre- and postoperatively.

The table lists the type of cases and the frequency of resident participation in preoperative care or postoperative follow-up.

This is important because on page 18 of the Residency Review Committee (RRC) for Surgery Program Requirements for Graduate Medical Education in General Surgery, the following is stated:

A resident may be considered the surgeon only when he or she can document a significant role in the following aspects of management: determination or confirmation of the diagnosis, provision of preoperative care, selection, and accomplishment of the appropriate operative procedure, and direction of the postoperative care.

If you interpret this literally, in not one of the 228 cases that were done was the resident who performed the procedure entitled to consider herself the surgeon for purposes of taking credit in the eyes of the RRC.

Continuity of patient care is also part of the professionalism core competency.

This is not the first paper describing this problem, nor is it the first paper to find that no residents followed a single patient all the way through the process.

What is the cause of this problem? Its not the length of the rotations because the shortest rotation for a senior resident was six weeks which should have afforded the residents ample time to have established complete continuity in at least a few cases.

The authors should be commended for their candor in reporting these findings. Had their paper been published 20 or 25 years ago, their program would have been cited by the RRC for a deficiency in continuity of care.

It’s an even bigger concern in community hospital surgical programs where the majority of elective patients come from private practice offices.

Whats the solution? The easiest fix would be to change the RRC requirement. What is the point of having a rule that cant be followed?

The residents are not learning about making the diagnosis, deciding whether to operate, the informed consent discussion, and evaluating the patient after discharge from the hospital.

The real issue is that there is much more to surgery than simply doing the operation.

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Meaningful Use Stage 3 Is Coming Should Be Fun

An alert reader tipped me off to something many of you may not be aware of. Stage 3 of Meaningful Use is close at hand.

The "proposed" rules will be officially published on March 30. The good news is that comments will be received for a couple of months.

The bad news is that if the Office of the National Coordinator for Health Information Technology is anything like every other regulatory body Ive ever dealt with [e,g., the ACGMEs Residency Review Committee for Surgery], the "proposed" rules will be the real rules and the comments will be simply a way for disgruntled physicians to vent.

If you dont believe me about the venting, take a look at the 185 mostly negative comments posted on Medscape’s story about Stage 3.

Here are a few of the new rules that will be in effect by 2017 or sooner.

More than 25% of patients seen by an eligible professional (EP) or discharged from a hospital or emergency department (ED) must "actively engage" with their electronic health records (EHRs).

When I was practicing, I had trouble getting some patients to take their medicine or even get out of bed. I don’t know where the people making these rules live, but most of my former patients were highly unlikely to actively engage with their electronic records. I suppose as is the case with unplanned readmissions of noncompliant patients, penalties will be handed out if only 24% of one’s patients engage their records.

Patient-generated data from a nonclinical setting must be incorporated into the EHR for more than 15% of patients seen by the EP or discharged from a hospital or ED.

A “nonclinical setting” is something such as home health care or physical therapy. How anyone is going to be able to track this? Did they mandate only 15% because they know this will be nearly impossible to comply with?

EPs and hospitals must use their EHR to create a summary of care and electronically exchange it with other providers for more than 50% of transitions of care and referrals. In more than 40% of these transitions of care, the provider has to incorporate in its EHR a summary of care from an EHR used by a different provider. In more than 80% of transitions of care, the provider has to perform a "clinical information reconciliation" that includes not only medications and allergies, but also problem lists.

EHRs from different vendors lack "interoperability." They dont communicate very well with each other. “Copy and paste” is out of control now. Wait until you see what happens when people try to comply with these transition of care rules—assuming that EHRs from other doctors can even be opened. This is going to be a monumental amount of work, all of which of course will be uncompensated.

I retired more than two years ago. In social situations, I’m often asked, “Do you miss being a doctor?” I miss the satisfaction that came from helping patients and most of the people I worked with, but I don’t miss the ever-expanding bureaucracy, regulations, and busywork associated with practicing and teaching surgery.

Old age has its rewards. One of them is not having to deal with Stage 3 or even Stages 1 and 2 of Meaningful Use.

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