Ideal Medical Practices

IMPcamp09 blogging contest with Sermo support

To all current and potential 2009 IMP Camp attendees:

How would you like to get paid to go to IMP Camp? In collaboration with Sermo, an online physician forum, we are looking for some intrepid soul with the fortitude and gumption to take on the arduous role of "Official IMP Camp Blogger" for the upcoming IMP Camp in Seattle, WA from August 14-15th.

Here's the deal:
1. Contest is only open to physicians who will be attending IMP Camp 2009 in Seattle.
2. To enter, submit an article on the general topic, "My Ideal Medical Practice". It can be about the practice that you've always dreamed of but don't know how to achieve, the practice that you already have and how you want to improve it, why you are going to IMP Camp, why you gave up a promising career as an American Idol to become a doctor, or some other interesting angle. We value creativity here.
3. All entries may be posted on the Ideal Medical Practices blog, and may be edited for grammar, spelling and editorial discretion.
4. The winning entry will be selected by Gordon Moore, MD.
5. The winner would become the "Official IMP Camp Blogger" and post 4 to 6 daily updates while attending IMP Camp that will then be published on Sermo. You can either bring your laptop to camp or we will provide you with Internet access. You need to be comfortable using e-mail and be willing to work with a Sermo representative who will give advice/coaching. Obviously, you would need to join Sermo which is free.
6. After IMP Camp is over, you would be expected to check in at Sermo over the next 7 days for follow up and feedback about your experiences.
7. In return for all your talent and hard work, you will receive a $200 Honorarium courtesy of Sermo and eternal fame throughout the blogosphere.
8. E-mail your entry to: glseto (at)mac.com.
9. Entry deadline is midnight, July 31st, 2009.
10. So break out your keyboards and fountain pens and start writing. Good luck!

Gary Seto
South Pasadena, CA

Grateful

I met Beatrice (not her real name) a little more than 2 years ago. She had just turned 90, and her daughter brought her in because she had been feeling a little more tired and short of breath lately. As she put it, she was having problems "getting going" in the morning. She had rarely been to a regular medical doctor, preferring homeopaths, in line with her beliefs as a Christian Scientist. 

Up until a year before, she had been living for 19 years in Ojai, CA, 9 of them with her husband who passed away 10 years earlier of lung cancer. She had been active and doing yoga up until 1 year earlier when she fell and broke her arm. Ever since then, she had been living in an assisted living facility closer to her daughter. She had also been developing signs of Alzheimer's dementia over the past 4 years.

Beatrice was a pleasant and cheerful woman who acknowledged having some memory problems but kept repeating over and over again how “grateful” she was for her life so far. She proudly told how she was one of the first female bank tellers before she became a permanent homemaker. She also mentioned how throughout her life she never liked to take medicine or see doctors. 

After examining her, I discovered that she had atrial fibrillation causing mild congestive heart failure, which was also the cause of her shortness of breath and fatigue. She also scored 13 out of 30 on her Mini-Mental State Exam, consistent with moderate dementia. Beatrice went home without any medications because her daughter wanted more time to think about what to do next. This first visit took 90 minutes.

After a series of e-mail communications and a follow up visit, we agreed to start Beatrice on some medication to help her breathe better. Over the next few months, she gradually improved with medication to the point where she was breathing comfortably again. Her daughter told me that while Beatrice couldn’t remember anything about what we had talked about, she did remember me and liked me. 

I would see Beatrice several times for follow up over the next 12 months, and even though she couldn’t remember what she had for breakfast, each time she would smile and say how “grateful” she was for everything. That seemed to be the one thing she would never forget. She remained stable as far as her breathing but her dementia continued to worsen ever so slowly, and eventually she started having trouble with agitation and even remembering who her daughters were sometimes.

Unfortunately, this happens all too often with many elderly patients in this day and age. Even as you wonder if this is the kind of life they, or anyone, would want to have, it is often too hard to stop giving medications that you know are helping to keep someone alive.

In a typical busy doctor’s office, there just isn’t enough time to talk about what is really important to her or her family. It would just be assumed that we should just do our best to keep her heart from going into rapid A-fib and developing congestive heart failure, and to do otherwise would be unmerciful. And so, Beatrice would continue to take her Digoxin and Lasix, and her mind would continue to gradually wither away, losing bits and pieces of herself as time went on. 

And eventually she would get a stroke and lose her ability to walk, speak or feed herself. Or she would fall trying to get out of bed in the middle of the night and break her hip. And she would end up bedridden and develop pressure ulcers on her fragile skin. And finally, if she didn't die of something else first, she would end up in a “persistent vegetative state”, her self-awareness gone, left with only a thin, frail body curled up in a nursing home bed, kept from malfunctioning further with well-intentioned medications, waiting to die.

That is, she would have if she had received care as usual. 

Instead, I had long discussions with Beatrice’s two daughters that started 9 months ago, in person, by phone and by e-mail. We discussed the likely outcomes of continued treatment along with that of stopping treatment. We discussed adding medications to treat her agitation and anxiety and their potential side effects. We discussed what Beatrice valued in life, what her preferences would have been and what she would have chosen for herself, if she were able. We discussed their concerns that their mother not suffer. 

After 4 months of discussion and reflection, her daughters decided that a palliative approach was what their mother would have wanted and started inquiries into hospice programs. A month later, she had enrolled with a hospice program, and I stopped directing her medical care, since the hospice program already had a physician. 

Yesterday, I received an e-mail from Beatrice’s daughter saying that, after a few weeks of terminal agitation, her mother had passed away peacefully. 

I’d like to think that Beatrice was grateful to go this way. 

I'd be grateful if every primary care physician could be given the time and paid for the time to do the right thing for their elderly patients, rather than give "care as usual".

Gary Seto, MD

South Pasadena, CA

IMP Question of the Week: E-prescribing

This week's question is from Jean:

Q: Gary, what is your personal take on this e-prescribing mess?

Do you see Medicare? Medicare is huge here. Maine is very old. I have been ignoring e-prescribing. My EMR has it now enabled but it will cost a whopping $1200 a year. I might make more than that in incentives for the first couple of years but then not. Plus you have to code it....

I suppose i could do something free or low cost - but that is double entry.

Anyway what is YOUR take? Thanks.
Jean

A: Jean, thanks for asking and I'm glad to hear that Maine is very old. That means you get to have a steady stream of patients for your practice. Then again, that means putting up with more Medicare hassles. On second thought, you have my sympathies. 

I opted out of Medicare in 2008. I assume you brought up Medicare and e-prescribing together because of Medicare's new E-prescribing Incentive Program. Starting January 1st, 2009, physicians can get an incentive payment for being a "successful e-prescriber": a 2% bonus in 2010, 1% in 2011 and 2012 (assuming the world doesn't end first), and 0.5% in 2013.

Like many things associated with Medicare, it seems kind of complicated: 

1. You must use a "qualified" e-prescribing system such as a stand-alone system or one that is integrated into your electronic health record (EHR).
2. You must report the electronic prescription to Medicare using a special "G-code".
3. At least 10% of your total Medicare charges must use the e-prescribing codes.
4. You have to report G-codes for at least 50% of all submitted claims.

Complicated bureaucracy like this is one reason why I no longer participate in Medicare.

Anyways, if you collect $60,000 from Medicare for the year 2009, then qualifying for the e-prescribing incentive will get you an extra $1200. Just enough to pay for your EHR's e-prescribing service. You break even.

If you collect more than $60,000 in 2009 from Medicare, then you might actually make some money. And if you make less than $60,000 in 2009 from Medicare, you will end up losing money. 

So if you decide to go for the e-prescribing incentive, it probably makes more sense to enroll in a free e-prescribing service such as AllScripts eRxNow. True, it does require you to do double entry, but in a typical small IMP practice where you see less than 10 patients/day, that is not overly burdensome. Plus once a patient has been entered into the system, you don't have to re-enter their information again. 

I did try the eRxNow service for a few months and found it relatively straightforward and easy to use. However, I stopped using it because I found out that I could also e-prescribe using RelayHealth, which I was already paying for. I figured that I might as well get my money's worth.

Both e-prescribing systems are similar in that you have to enter the patient's name and some demographic info. Which brings up my first e-prescribing fact:

1. E-prescribing does NOT save time for physicians.

Writing a NEW e-prescription is always going to be slower than writing a paper prescription. The system won't let you proceed until you have entered in all the required information. Then when you try to find the medication, it may give you more choices than you knew were available. Or it may not have the right medication or dosage in the system at all. 

Fortunately, with time, you get faster. You can have a "Favorites" list of your most prescribed medications with the preferred dosages and directions that you can just point and click on. Unlike new prescriptions, online medication refills can be faster than calling/faxing, especially if you have a lot to do at one time.

You also can't e-prescribe controlled substances, which is probably a good thing, although my prescriptions for Ambien seem to go through without callbacks.

2. E-prescribing does NOT necessarily save time for patients.

Again, if it takes you time to enter the e-prescription, then it takes patients time to wait for you to finish. Even after you hit "Send", things don't always go smoothly. I usually tell patients to give the pharmacy an hour to get their prescription ready. 

I think I must have been one of the first physicians in the area to use e-prescriptions because for the first few months, I would have the pharmacy call me after the patient left and say, "Mrs. Jones is here to pick up her prescription but we haven't received anything yet." And then I would have to give a verbal order. 

Or even worse, after the patient is told there is no prescription waiting for them, they go back later hoping that it will be there now. But you never hear about it until they call or e-mail you to ask, "Did you send my prescription?"

3. E-prescribing still has bugs in the system.

At least once every few weeks, I will get a call from a pharmacy or patient saying that the e-prescription never got through. It seems to happen more when I send an e-prescription to a new pharmacy or to certain e-prescription-unfriendly pharmacies. In almost every case, when I'd tell the pharmacy technician to check their fax machine or e-prescribing system, they eventually found it. It's almost as if the pharmacies don't want doctors to e-prescribe.

Another glitch is when I get a fax from the pharmacy requesting a refill. I send an e-prescription refill and it's done, right? Then the next day, I get the exact same fax. I figured they just haven't had time to figure out that I sent in the refill order. But then they keep coming every day, until I call up the pharmacy and point out that I already sent an e-prescription and to stop sending me these automated refill requests please!

4. E-prescribing might mean safer prescribing.

The proponents of e-prescribing claim it leads to greater patient safety because they are clearer to read with less chance of errors, and that is definitely true. But it is not true that you will have access to your patient's entire prescription history, unless you are the only doctor who ever writes prescriptions for them. It will not have prescriptions written by other physicians, so you still have to get a complete medication history from your patients to check for drug interactions. 

5. E-prescribing makes you look cool.

E-prescribing is the medical IT equivalent of having an iPhone. It impresses upon patients that you are technologically-savvy and ahead of the curve. They probably wouldn't even notice that you can't type. What would be even more impressive is if I could e-prescribe quickly and easily from my iPhone. 

Like many cutting-edge technological advances, e-prescribing is a wonderful concept that in real-life practice, is inconsistent, and sometimes frustrating. For me, it works about 80-90% of the time. I keep plugging away at it because I know that if I stop, it will take that much longer for e-prescribing to be widely adopted. We are the beta testers for the pharmaceutical industry, and if anything, we should be the ones getting paid to work out the bugs in their system.

The Medicare E-prescribing Incentive Program is an example of how well-meaning health care policy decisions to use technology, whether it be EHRs or quality reporting, often don't make the work of primary care any easier, and in fact, adds even more work with burdensome requirements. We need solutions that are simple to understand and implement. 

So, Jean, bottom line is I think e-prescribing is definitely part of the future of medicine, and an important part of my IMP practice. If you decide that now is the right time for you to start e-prescribing, then hopefully it won't cost you too much time or money to implement it. 

Gary Seto, MD

South Pasadena, CA

I have a dream

Welcome to the Ideal Medical Practices blog! I was invited by Dr. Gordon Moore to share my thoughts along with those of various other physicians involved in the Ideal Medical Practice or IMP movement, a grassroots attempt at solving our nation's dysfunctional healthcare system. 

I am a family physician located in South Pasadena, CA and have been operating a solo micropractice for the past 5 years. I left a large HMO after 13 years frustrated at the lack of time available for me to do the job I was trained to do, and I got tired of running on the hamster wheel. Now I am like over a hundred other physicians and health care providers around the country, trying to find a better way to care for patients by keeping my practice small and personal.

In light of it being Martin Luther King Jr. Day today, I thought I would voice some of the dreams I have for the future of healthcare in America.

I dream of the day when every person in America has access, not just to insurance, but to affordable healthcare. Because insurance without access is like a key with no door or a fork with no food -- not very useful.

I dream that there will come a time when there are no restrictions to healthcare due to "pre-existing conditions" and that people can continue to receive healthcare no matter what their job is and even if they have no job at all.

I dream that America will wake up and realize that the foundation of healthcare is in basic primary care; that it will finally fix the perverse incentives that reward procedures over thought, specialists over generalists, rescue over prevention.

I dream that the proposal being made at http://www.patientsatcenter.org/petition.html comes true, and that a consistent stream of healthcare money goes towards basic primary care, maintaining wellness and preventing disease.

I dream that young and idealistic men and women will once again heed the calling to provide primary care to the people, and be financially and spiritually rewarded for their hard and caring work. That they won't be beaten down by the crying masses, long hours and endless paperwork that has been forced upon them in an misguided effort to save a few bucks on the backs of overworked primary care doctors.

I dream that mental illness will be recognized as being no different than bodily illness and that healthcare providers and patients can be given the resources necessary to treat them, and that insurance companies no longer discriminate against the people who happen to suffer from them.

I dream that the CEOs, board of directors, stockholders of health-related companies, be they insurance plans, pharmaceutical companies, hospitals, medical groups, place the value of the health of their customers above that of profit and greed. 

I dream that pharmaceutical companies will price their products affordably, stop direct marketing to consumers, stop developing medications that have no significant benefit other than to maintain their profits, and stop slanting medical research to favor their products.

I dream that vitamin and nutritional supplements will finally be regulated in the same manner as prescription medications, and have to prove safety before they are allowed to be sold, as well as efficacy before they are allowed to claim that it is helpful in maintaining the health of any bodily organ. 

I dream that malpractice lawsuits are replaced by a fairer judicial system that doesn't depend on sympathy, specialists who act as "hired guns" or skilled jury selection, that utilizes consistent medical guidelines/standards and an understanding that no doctor, being human, can be flawless.

I dream that each person in American learns to take responsibility for his or her own health care, and realizes that it is what we do every day that determines our health; that taking care of our bodies with healthy foods and regular exercise; that keeping harmful habits and substances away from our bodies will do far more in keeping us healthy than any pill or medical treatment.

I dream that the American public learns to accept mortality, and that there are limits and medicine, like life, is imperfect; that death is not optional and is a necessary part of life; that heroic efforts to stave off death at any cost are costing other lives by draining limited resources.

I dream that the health of the planet we call home will be recognized as vital to the health of humanity, and that appropriate actions will take place to make our home a healthier place for all to live.

While I know most of these will not take place in my lifetime, we've got to start somewhere and that somewhere is usually in a dream. After all, MLK's dream led to the fulfillment of Mr. Obama's dream. Who knows what other dreams may come true tomorrow? 

Dream on.

Gary Seto, MD

South Pasadena, CA