Category: Outpatient Practice

Categories
Outpatient Practice

Prescribing Oxygen

It is pretty common to have to start a patient on home oxygen after discharge from the hospital but ordering oxygen for home use is much different and much more complicated than ordering oxygen in the hospital. The good news is that our patients have more options than ever before but the bad news is that with more options comes a lot more complexity. In this post, I’ll summarize what you need to know about prescribing home oxygen.

The first thing to understand is how Medicare covers home oxygen. Most insurance companies follow whatever Medicare decides, so knowing the Medicare rules will generally apply to other insurance companies. When you order home oxygen through a respiratory therapy company, Medicare will pay that company to provide oxygen for up to 36 months. Medicare pays 80% of a fixed amount each month that is supposed to cover the rental of the oxygen equipment (concentrators, oxygen tanks, etc.) plus supplies (oxygen tubing, etc.). This amount varies depending on the geographic location in the country and the specific billing codes used but the Medicare reimbursement is generally in the $150-$200/month range. The patient (or the patient’s supplemental insurance) is responsible for the other 20%. After 36 months, the company has to provide the equipment for 24 months (for free) and Medicare will only reimburse that company a small amount for a “service charge”. After 5 years, the cycle starts all over again. The key operative here is that Medicare will pay to rent equipment but not to buy equipment. This is important because after 3 years, the total amount that a respiratory therapy company can get for rental of expensive equipment, such as a portable oxygen concentrator (total cost about $2,500) is often not enough to cover the cost of that equipment and since the company is then required to supply that equipment for free for the next 2 years, by the time 5 years is up, the equipment is fully depreciated and can’t be re-rented to another patient. The Medicare pricing for the various oxygen HCPCS codes for each state can be found at the CMS Noridian website. Prescribing oxygen requires the physician (or NP/PA) to fill out the Medicare oxygen CMN (certificate of medical necessity) form – this form is usually sent to the patient’s outpatient physician after discharge from the hospital; therefore, having all of the required oxygen qualification information documented in the inpatient medical record or in the discharge summary can make it much easier for the patient’s primary care physician to gather the information necessary to complete the CMN.

In order for Medicare to cover oxygen, the patient has to have a qualifying oxygen level. Furthermore, there has to be documentation that the patient’s oxygen level improves with supplemental oxygen. Therefore, you have to have in the chart the following:

  1. Documentation that the oxygen level is low
  2. Documentation that the oxygen level can be restored to a normal level with supplemental oxygen
  3. The amount of oxygen (in liters per minute) that are necessary to return the oxygen level to an acceptable oxygen saturation level.

There are several ways that a patient can be qualified for coverage for home oxygen. The oxygen level can be low at rest, while sleeping, or with exertion. The following are the thresholds that Medicare requires:

  1. Resting PO2 < 55 or oxygen saturation < 89%
  2. Oxygen saturation < 89% during exercise (for example, walking in the hall)
  3. Oxygen saturation < 89% for > 5 minutes while sleeping

Testing for home oxygen is most commonly done with an “oxygen titration study” (sometimes called an oxygen qualification test). During this test, the oxygen saturation measured using an oximeter and then the patient walks until their oxygen saturation drops below 89%. The patient is then given oxygen and it is turned up to the flow rate necessary to keep the oxygen saturation above 89% while walking.

Once oxygen is prescribed, there are several choices you will need to make. Often, oxygen equipment is obtained from a home health or home respiratory therapy company. These companies will usually have several different options for home oxygen and can help the patient select the oxygen option that is best for them. However, because of the way that Medicare pays these companies for home oxygen (monthly payments for rental of oxygen equipment), some oxygen delivery devices, such as portable oxygen concentrators, are not cost-effective and thus not offered by all home oxygen companies. Patients can also purchase oxygen concentrators directly from the manufacturers (more on that below).

There are three equipment options for home oxygen: oxygen concentrators, compressed oxygen gas, and liquid oxygen.

  1. Stationary oxygen concentrators. These are electrical devices that concentrate the oxygen that is in the regular air. Stationary oxygen concentrators are large machines about the size of a large suitcase that are meant to be kept in one location in the home. Patients can connect oxygen tubing up to 50 feet in length for mobility within their house. There are two general types of stationary oxygen concentrators: those that go to 5-6 L flow rate and those that go up to 8-10 L flow rate (“high flow” concentrators). Although these can be purchased directly from manufacturers, most patients rent a stationary oxygen concentrator from a home respiratory therapy company.
  2. Portable oxygen concentrators. These are smaller devices that are about the size of a toaster and weigh about 4-7 pounds. They are electrically powered and can be run off of batteries, a regular wall socket, or an automobile’s electrical system. The batteries are rechargable and can last up to 10 hours depending on the oxygen flow rate setting. Most portable oxygen concentrators will provide up to 4 L oxygen flow but some of the larger devices will go up to 6 L oxygen flow. Most portable oxygen concentrators will deliver oxygen by either “continuous flow” or “oxygen conserving flow”. Continuous flow means that the oxygen flows continuously whether you are breathing in or out. Oxygen conserving flow means that the oxygen only flows when you are breathing in. Because it takes energy to make the oxygen, the battery will last longer when set to oxygen conserving flow. Portable oxygen concentrators are a good option for patients who are frequently out of the house, who have a house big enough that 50 feet of oxygen tubing is insufficient, who travel by car, or who travel by airplane (portable oxygen concentrators are the only oxygen equipment permitted by commercial oxygen companies). Some home respiratory therapy companies will offer at least one brand of portable oxygen concentrator but there are many companies that make oxygen concentrators and for many patients, it is easier to purchase their own portable oxygen concentrator directly from the company in order to get the specific brand that they prefer. Most portable oxygen concentrators cost about $2,500 to $3,000. Some of the popular brands include: Inogen, Airsep, Inova, Respironics, and Invacare.
  3. Compressed oxygen gas. These are supplied by a home oxygen supply company or home health company. There are many different sizes of the oxygen cylinders. Very large stationary tanks (H cylinders) are designed to be back-ups to the stationary oxygen concentrators (for example, in event of a power outage) and are meant to be left in one place in the home (they are not portable). Medium sized tanks (E cylinders) are designed to be pulled in a wheeled cart that looks a little like a cart used to carry a golf bag. They are difficult to get in and out of cars and are difficult to go up and down stairs with; depending on the flow rate, these will usually last 2-8 hours. Small sized tanks (M-6 cylinders) are designed to be carried over the shoulder or in a backpack. The small sized tanks are usually used with an oxygen conserving device to make them last longer; depending on the flow rate, these will usually last 1-4 hours. Many of the small sized oxygen tanks can be recharged from a stationary oxygen concentrator.
  4. Liquid oxygen. Oxygen in liquid form is much more dense than oxygen in gas form. Liquid oxygen reservoirs are devices that are about 2-3 feet tall and plug into the wall electrical socket. The reservoirs are very heavy and cannot be moved around the house easily. They will usually last several weeks and then are replaced by a home oxygen supply company. One advantage of liquid oxygen reservoirs is that they can be run at a very high oxygen flow rate (10-15 L) for patients who require a lot of oxygen. Liquid oxygen can also be used with small portable tanks that weigh 3.5 to 5.5 pounds (for example, Helios brand). An advantage of the portable liquid oxygen tanks is that they last much longer than compressed oxygen gas tanks (usually 4-22 hours depending on the flow rate and size of the tank). The portable oxygen tanks can be quickly refilled from the liquid oxygen reservoir.

Practical tips for using oxygen for patients:

  1. Be sure that you plan ahead when traveling outside of the house so that you do not run out of oxygen. Always take extra tanks or batteries (for portable concentrators) in case your traveling takes longer than anticipated.
  2. Do not take your oxygen off in the shower – water will not hurt the oxygen tubing. Keep any electrical equipment (such as oxygen concentrators) outside the shower so the electrical equipment does not get wet.
  3. If you use a higher flow rate with exercise than when you are at rest, turn the oxygen to the higher flow rate a minute or two before you begin your activities. For example, if you need 2 L flow at rest but 5 L with exertion and you are getting ready to walk up the stairs, be sure to turn the oxygen up to 5 L before you get up to walk up the stairs.
  4. You can purchase a finger oximeter at your pharmacy or on-line to help guide your oxygen flow rate. These cost as little as $35.
  5. Do not smoke in a house with oxygen equipment in it. Also, do not use your oxygen when you are around open flames (such as a gas oven or gas grill). Above all, never smoke while using oxygen – it will cause serious or even life-threatening burns to the face and nose.
  6. Let your power company know that you are on oxygen so that your home can be targeted to have power restored earlier in event of a power shortage.
  7. Let your local fire department know that you have oxygen in the home. Consider placing an “oxygen in use” sign on the door.
  8. Oxygen can dry out the nose and this can result in the nose feeling dry, nose bleeds, or sometimes an excessively watery nose (as the nose tries to counterbalance the drying effect of the oxygen). If this happens, try using over-the-counter saline nose spray every few hours to keep the nasal passages moist. You can also use water-based lubricants (such as K-Y jelly) but do not use oil-based lubricants (such as vasoline).
  9. You cannot get addicted to supplemental oxygen. Either you need it or you do not need it but you will not become dependent on it just by wearing it. Sometimes, you may need to use the oxygen more often that usual, for example, if you get pneumonia. Once the pneumonia clears up, you can usually go back to your previous oxygen flow rate.

My Bias:

Personally, I like the portable oxygen concentrators. If money is not a barrier, I think purchasing (or renting) a stationary concentrator for primary home use plus also purchasing a portable concentrator for use outside of the home gives patients the most freedom and convenience. With home oxygen options, you get what you pay for and even though the better-made portable concentrators are more expensive and are often not be covered by Medicare, they can make life much easier. For patients who don’t have $3,000 to buy a stationary plus portable concentrator, a home respiratory therapy company can help tailor the equipment that would be covered by Medicare to the patient’s personal needs.

September 23, 2017

Categories
Outpatient Practice

Size Matters: What Is The Best Patient Panel Size For A Primary Care Physician?

In the past, we assessed how productive a primary care physician was by how many RVUs he or she generated. With the move toward accountable care organizations, quantity of visits is less important than value of care. Primary care physicians are often employed by hospitals or, in the case of academic medical centers, they are subsidized by the health system. So, we need to find another way other than RVUs to determine if the primary care physician is working at 100% effort.

One way of doing this is by the physician’s panel size. This is the number of patients that that physician is the primary care provider for. But there are a lot of problems with using panel size as a productivity metric because it is very easy to game the system. There are a lot of numbers thrown around about the optimal patient panel size. Historically, an often quoted number is 2,500 but this value was calculated on some flawed assumptions. More recently, many studies suggest optimal panel sizes from 1,300 to 1,900 per physician. So, what is the correct number? As with most things in medicine… it depends. There are a myriad of variables that affect the number of patients that a primary care physician should have in his/her panel. Here are a few:

  1. Panel maturity. By that, I don’t mean how old the patients are but rather how long the physician has been seeing those patients. For a physician straight out of residency, every patient is a new patient and requires a lot more effort to get them plugged into specialists, a preventative medicine calendar, etc. Those new patient visits take a lot more time and often need shorter interval initial follow up visits. For a first year primary care physician to achieve a panel size of 1,900 in the first year out would require him/her to see 8-9 new patient visits per day and this is really not achievable.
  2. Physician maturity. The more experienced the physician, the more efficient they get in the office. The same thing happens with ER physicians, hospitalists, and surgeons. A physician who has 20 years of practice experience can comfortably manage more patients than a physician straight out of residency.
  3. Clinic maturity. Efficiency in patient flow and management is not just dependent on the experience of the physician but the experience of the nurses and office staff and how well they function together as a team.
  4. Patient maturity. The intensity of primary care is age-dependent with the greatest intensity at either extreme of age. For a pediatrician, taking care of 1,500 children all under age 2 years old is a lot different than taking care of 1,500 13-year olds. Similarly for a family physician: a panel made up mostly of 25-year olds is much easier to manage than a panel the same size made up of 75-year olds. Geriatricians take care exclusively of the elderly and these are patients with more medical problems and psychosocial needs than working age adults; consequently, the geriatrician will have a smaller patient panel than a typical general internist.
  5. Illness complexity. I know some primary care practices composed of a mixture of family practitioners, pediatricians, and internists. The children with more complex health needs, such as cerebral palsy and diabetes, are followed by the pediatricians. The adults with more complex health needs, such as advanced COPD and severe systolic heart failure, are followed by the internists. The rest of the patients are followed by the family medicine physicians. In this model, each patient gets assigned to the physician best equipped to take care of that patient but the pediatricians and the internists care for the most complex patients and generally require a smaller panel size than the family medicine physicians. Similarly, in a large primary care practice that has one physician who manages all of the patients with autism (who require more total physician time per patient per year), that physician will need to have a smaller panel size but taking care of all of the autistic patients, the other physicians will be able to handle larger panel sizes.
  6. Use of advance practice providers. These are usually nurse practitioner or physician assistants. They may see patients independently, in which case they have their own panel of patients – usually smaller than the physicians. Or they may be used to amplify the productivity of the physician by performing less complex clinical tasks that free the physician up to manage more complex tasks. For example, a primary care physician may work with a nurse practitioner who does all of the routine health maintenance visits and preventive care visits thus freeing the physician up to see new patients and visits for new or acute problems. In this model, the physician can maintain a much larger panel size than the primary care physician who is a solo practitioner without a nurse practitioner. There is a solo family physician in our community who manages thousands of patients in an enormous multistory clinic building. He does it by employing an army of nurse practitioners and physician assistants and then he only sees those patients that the NPs or PAs have questions about.
  7. Use of health specialists. Yes, the physician can spend an hour counseling a patient on a diabetic diet. But a dietician’s time is less expensive than a physician’s time. Having clinic staff who can teach patients how to use inhalers, monitor INRs to adjust Coumadin dose, do smoking cessation counseling can all free up the physician to do other activities. Therefore, dietitians, pharmacists, and health educators can equate to a larger panel size.
  8. Health literacy of the patient population. The greater the health literacy of the patients, the easier it is to manage those patients and the easier it is to maintain a higher patient panel size. The same applies to access to healthcare of the patient – it is much simpler to manage a patient with good health insurance than it is to manage a patient with no insurance when it comes to getting medications, tests, and consultants.
  9. The patients’ language. In my own practice, I take care of a lot of elderly Russian-speaking immigrants, French speaking patients from Africa, and Somalis. Each patient encounter takes longer because of additional time that it takes to communicate through a translator. Furthermore, the physician practice is generally responsible for arranging translation and this adds practice expense. The more non-English speaking patients in the panel, the smaller the panel size should be.
  10. Office design. The physical structure of the clinic can have a huge impact on efficiency of patient flow and on how many patients can be seen. This translates to more patients that the primary care physician can comfortably manage in the panel. Having a sufficient number of exam rooms per physician plus easy access to basic testing such as x-ray, EKG, and lab equates to higher panel size.
  11. Clinical education. Medical students represent the next generation of physicians and it is our professional obligation to ensure that the next generation is well-trained. However, medical students can slow you down since, for Medicare compliance purposes, the attending physician has to re-take the history, do a complete exam, and then do nearly all of the progress note documentation. That means that the clinical care time from the physician’s perspective is about the same whether there is a medical student or not, but once you factor in additional time to actually teach the medical student, the time costs add up. Fortunately, most physicians get inherent reward by educating students and so we would accept a smaller panel size, even it it meant a smaller salary, in order to be clinical educators.
  12. The definition of who is in the panel. Our electronic medical record is great – it is very easy for me to see how many individual patients I saw in the office last year. However, if you use the EMR to calculate the panel size of a primary care physician by calculating how many individual patients that physician saw in the past year, you’ll get bad data. Inevitably, there will be times when the primary care physician will be cross-covering for a partner or will be taking acute illness calls or will be the physician in the office on the day that all of the practice’s patients come in for their flu shots. You have to have an accurate way of identifying those patients who are truly associated with each individual primary care physician as their physician of record.
  13. Coordination of care with specialists. In a health system with good inter-physician communication with an electronic medical record and where specialists assume longitudinal management of specific medical problems, the time and effort required by the primary care physician for coordination of care is less and this translates to an ability to manage a larger patient panel. For example, if a patient is found to have pulmonary nodule and the primary care physician can refer that patient to a pulmonologist who will assume responsibility for further testing and follow-up of the nodule, then that frees up a lot of the primary care physician’s time. Some primary care physicians have a practice philosophy of “a consult is a sign of weakness” but these physicians can get tied up spending more time trying to manage highly specialized or complex diseases that could be managed more efficiently by coordinating management with a specialist.
  14. Disease diversity. By this, I mean the homogeneity of the spectrum of health problems that the primary care physician sees. For example, being a general family physician is very challenging because you have to be familiar with the health maintenance requirements and preventive health needs for children all the way through the elderly. You have to be facile with gynecology (and sometimes obstetrics) as well as minor surgery. That is a lot of areas to keep up on from an education standpoint. This can limit the panel size. On the other hand, a primary care physician who limits their practice to one age group or one gender has a more focused patient population and in theory, can often manage a larger number of patients.

In summary, there is not a “one size fits all” when it comes to primary care physician patient panel size. My own take on panel size is that more than 2,500 is probably too many for the typical primary care physician and less than 1,000 is probably too few for the typical primary care physician. Whether an individual physician should have a panel size closer to 1,000 or closer to 2,500 depends on all of the variables above.

August 27, 2017

Categories
Inpatient Practice Outpatient Practice

The Future Of Telemedicine Is Now

Telemedicine. It is an idea that just seems to make so much sense but it has had a hard time getting much traction in the United States. But recently, economic forces are causing telemedicine to become a viable option in a number of areas. Here is how we are using telemedicine in our hospital:

Prison medicine.

For more than 25 years, we have had a telemedicine program with the Ohio Department of Corrections. Inmates with medical conditions requiring more than basic primary care go to a video camera set up in the infirmary of Ohio prisons where there is 2-way video communication with a specialist at the Ohio State University Wexner Medical Center. There is a nurse at the prison-end who can do physical examination directed by the physician at the OSU-end and there is an electronic stethoscope for auscultation.

Why it works: It is cost effective for the Department of Corrections. It costs a lot to transport an inmate across the state to be seen by a physician in person and there is security risks. It is far cheaper for the Department of Corrections to pay our medical center for telemedicine visits. Patients that do need in-hospital care for medical or surgical conditions are admitted to a locked-down prison unit at University Hospital.

Telepsychiatry.

Patients who come into the emergency department at University Hospital East are evaluated by a two-way video camera system by a psychiatrist located in a remote location. The psychiatrist can determine if the patient needs inpatient hospitalization in a psychiatric hospital or if they can be safely discharged from the ER.

Why it works: Our psychiatrists are based out of the main University Hospital campus where the inpatient psychiatry hospital is. My hospital, University Hospital East, is 9 miles away. A psychiatrist seeing emergency department and psychiatric observation patients would need to leave those patients and drive over to our hospital to see psychiatry patients in the emergency department. Telepsychiatry permits the psychiatrist to evaluate patients remotely, thus keeping the number of patients being boarded in the emergency department for psychiatric evaluation down.

Telestroke.

Patients presenting to the emergency department with an acute stroke get a quick screening head CT and then a stroke neurologist (a neurologist who has done an advanced fellowship in stroke medicine) evaluates the patient by a video system. The stroke neurologist then makes a decision about whether the patient should receive t-PA (a blood clot dissolving medication).

Why it works: From the time a patient with an acute stroke arrives in the emergency department, we only have an hour for the emergency department physician to do his/her assessment, get a head CT to be sure that there is not a tumor or bleeding in the brain, be assessed by the stroke neurologist, and then get the t-PA. If you go much beyond an hour, the stroke becomes irreversible. There are not enough stroke neurologists to have one in every emergency department 24-hours a day so the solution is to have a central “hub” (our main University Hospital) and then a few dozen “spoke” hospitals that can use telemedicine to connect to the stroke neurologist at the hub. My hospital, University Hospital East, is one of many spoke hospitals affiliated with Ohio State.

Teledermatology.

Hospitalist at University Hospital East can take a photo of a rash or skin lesion and load it into our electronic medical record. A dermatologist at a remote location can then look at the photo and determine if there is enough information to make a diagnosis, if a punch or shave biopsy of the skin is required (which can be done by our family physicians or general internists), or if an in-person consult is required.

Why it works: We don’t have a lot of dermatology consults in our hospital. The cost of a dermatologist driving 15-20 minutes each way to come to our hospital to see a consult is not cost effective – they can see a lot of patients in the office in that 30-40 minutes. Because most of the time, the dermatologist can make a reasonably confident diagnosis from the photograph, it allows the dermatologist to see more patients rather than wasting time in the car. We have also extended the teledermatology program to Ohio State primary care physicians who can take a photo of a rash using their smartphone, load that image into the electronic medical record, and then the dermatologist will give an opinion within 24 hours – far simpler than waiting 2 weeks for a new patient appointment; the medical center is currently funding this program since it is not covered by private insurance.

Teleradiology.

This one is a natural product of the computerization of radiology images. A radiologist can pull up an x-ray or CT scan from any computer, anywhere in the world, and read the radiology study.

Why it works: The images on the computer are every bit as good (and usually better) than the images on old-fashioned x-ray films. We have x-ray sites all over the city and this allows the radiologist to be in one location and give an immediate interpretation of an x-ray done at any of these sites and report them on our electronic medical record.

Telepathology.

At University Hospital East, we have a general pathologist on site. But sometimes, you need a pathology specialist to review and interpret the microscope slides of a biopsy. Also, we have a procedure called “endobronchial ultrasound” where a needle aspirate of a suspicious lymph node or lung mass is taken during a bronchoscopy using a tiny ultrasound at the tip of the bronchoscope to guide the needle to the right place. Normally, there a cytopathologist (a pathologist who specializes in looking at cytology slides) does an immediate stain of the cells removed from each pass of the needle to tell the bronchoscopist whether there is enough cells to make a cancer diagnosis or whether additional passes of the needle are required. In telepathology, the microscope slide is loaded into a special microscope that can be manipulated by a pathologist viewing the images from that microscope over the internet, miles away.

Why it works: The cytopathologist can be at one location and review slides being done simultaneously from multiple other locations without having to travel to multiple sites in a single hospital or to multiple hospitals within a hospital system. Also, if a surgical procedure runs late, an on-call pathologist at one hospital location can do a frozen section analysis of a specimen at a different location so that a second pathologist does not need to be called in to do the frozen section.

In the past, telemedicine has always been constrained by reimbursement: Medicare and insurance companies did not want to pay for something seen as less than a “real” face-to-face encounter. But there are other economic factors in play – it is too costly for hospitals to have a stroke neurologist, psychiatrist, cytopathologist, dermatologist, or radiologist physically located at all sites within a large medical center at the same time. So even though many of the telemedicine services mentioned in this post are not reimbursable, they are financially viable because they obviate the need for a high-cost specialist to have a lot of down time driving from one location to another.

If we move toward a capitated health care model, we will likely see telemedicine incorporated into other practices. Just imagine how happy patients would be to get a ring on their Skype program when their doctor is ready to see them, rather than having to drive to their doctor’s office, park, wait in the waiting room, and then wait again in the examination room to finally see the doctor who is (as all doctors always seem to be) running late. The only thing holding us back is economics.

June 6, 2017

Categories
Outpatient Practice

CG-CAHPS Survey Demystified

The HCAHPS survey is designed to let patients rate their hospital based on their satisfaction with the care provided during an inpatient stay. The CG-CAHPS survey lets patients rate their outpatient doctor or group practice. CG-CAHPS stands for “Clinician and Group Consumer Assessment of Healthcare Providers and Systems”. The information is publicly reported on Medicare’s Physician Compare website. In my case, the CG-CAHPS for all of Ohio State University Department of Internal Medicine outpatient physicians is reported in aggregate. However, internally, we get reports from Press Ganey that allows us to drill down on individual practice sites.

Here are the questions on the GC-CAHPS survey:

  1. If this was a visit for an illness, injury, or condition for care you needed right away, did you get this appointment as soon as you thought you needed it?
    • Yes
    • No
  2. If this was a visit for a check-up or routine care, did you get this appointment as soon as you thought you needed?
    • Yes
    • No
  3. In the last 3 months, if you phoned this provider’s office with a medical question during regular office hours, how often did you get an answer to your medical question that same day?
    • Never
    • Sometimes
    • Usually
    • Always
  4. In the last 3 months if you phoned this providers office with a medical question after regular office hours, how often did you get an answer to your medical question as soon as you needed?
    • Never
    • Sometimes
    • Usually
    • Always
  5. In the last 3 months, if this provider ordered a blood test, x-ray, or other test, how often did someone from this provider’s office follow-up to give you the results?
    • Never
    • Sometimes
    • Usually
    • Always
  6. During this visit, did you see this provider within 15 minutes of your appointment time?
    • Yes
    • No
  7. During this visit, did this provider explain things in a way that was easy to understand?
    • Yes, definitely
    • Yes, somewhat
    • No
  8. During this visit, did the is provider listen carefully to you?
    • Yes, definitely
    • Yes, somewhat
    • No
  9. During this visit, if you talked to this provider about any health questions or concerns, did this provider give you easy to understand information about health questions or concerns?
    • Yes, definitely
    • Yes, somewhat
    • No
  10. During this visit did this provider seem to know the important information about your medical history?
    • Yes, definitely
    • Yes, somewhat
    • No
  11. During this visit, did this provider have your medical records?
    • Yes
    • No
  12. During this visit, did this provider show respect for what you had to say?
    • Yes, definitely
    • Yes, somewhat
    • No
  13. During this visit, did this provider spend enough time with you?
    • Yes, definitely
    • Yes, somewhat
    • No
  14. Using any number from 1 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?
  15. Would you recommend this provider’s office to your family and friends?
    • Yes, definitely
    • Yes, somewhat
    • No
  16. During this visit, were clerks and receptionists at this provider’s office as helpful as you thought they should be?
    • Yes, definitely,
    • Yes, somewhat
    • No
  17. During this visit, did the clerks and receptionists treat you with courtesy and respect?
    • Yes, definitely
    • Yes, somewhat
    • No
  18. In the last 3 months, if you took any prescription medications, how often did you and anyone on your health team talk about all the prescriptions medicines you were taking?
    • Never
    • Sometimes
    • Usually
    • Always

There are additional questions about the patient’s demographics, education level, overall perception of health, and race.

The data is aggregated into different topics and then reported as the percent of patients rating that provider as “top box”. So, for example, in the case of question #17, the top box would be ratings of 9 or 10. Similar to the HCAHPS survey, the CG-CAHPS survey suffers from grade inflation. In our specific clinic location, 93.5% of patients rate us as top box, with either a 9 or 10 overall rating. You can see the average scores at the Agency for Healthcare Research and Quality website where you can see averages by region of the country, physician specialty, type of practice, etc.

Some of the questions can be misleading:

When a patient is seeing a consultant the, questions about whether the provider had your medical records is a reflection of whether the referring physician sent records – if the consultant did not receive records before the patient’s initial visit, they cannot request those records until after the patient has come for the office visit and signed a release form allowing that consultant to request outside records. Therefore, if the referring physician failed to send records, the consultant gets a bad rating for question #11.

Many lab tests can take 2-3 weeks before the results come back. If the GC-CAHPS survey is sent out 2 days after the office visit, the lab test results will not be available and so of course no one from the office will have contacted the patient with the results. You have been set up for failure on question #5.

A specialist is generally not going to talk with the patient about all of their prescription medications every visit. Lets face it, you don’t want your orthopedic surgeon talking with you about the inhalers your pulmonologist prescribed. Similarly, do you really expect your dermatologist, who you are seeing for a mole, to review with you every one of the 25 medications you are taking for heart failure, diabetes, and hypertension? You are going to take a hit on question #18.

Right now, the data is mainly just accumulating and being reported for large group practices (such as the OSU Department of Internal Medicine). I get my own personal patient satisfaction scores internally from our department. However, some health systems now publicly report individual physician scores from the CG-CAHPS (for example, University of Utah). For physicians who are aghast that this information could be made public, search yourself on the internet – you are already being ranked by your patients at websites such as Vitals, Angie’s List, and Healthgrades. That data is unfiltered and subject to error (for example, in Healthgrades, I am listed as a neurologist, not a pulmonologist).

So get ready, you’re being rated just like restaurants on Yelp or hotels on Trip Advisor.

March 14, 2017

Categories
Outpatient Practice

Why The Number Of Patient Phone Calls Are Increasing

Does it sometimes feel like you are getting more and more patient phone calls? Well, maybe you just are. Twenty years ago, there were some days that I would get no phone calls from my outpatients. Now, if I get less than 10, it is a really good day. So why are patients calling their doctors more now than they did in the past? I believe that it is a confluence of several different factors:

  1. Office visit co-pays. As medical costs have become more expensive in the past decade, insurance companies have looked for ways to keep their costs down. One way that they have done it is by increasing the co-pays that a patient has for each office visit. These are typically $20-50 per visit. In order to avoid having to pay out of pocket to see a physician for acute bronchitis, patients are increasingly calling, in hopes of getting a free diagnosis and treatment over the phone.
  2. Office schedule templates. As more and more physicians have become employed by hospitals or large group practices, there has been more emphasis on improving office efficiency and from this has come the concept of schedule template optimization. The advantage of this is that a physician’s schedule of outpatient visits is highly organized so that there is minimal “down time” when an exam room is empty and the office staff are unoccupied. The consequence of this is that it can be very difficult to squeeze in a patient for a short notice sick-call. Although many primary care physicians will have some sick call slots on their schedule templates, on some days there are more sick calls than there are open slots. Many specialists do not have sick call slots on their schedule templates.
  3. The culture of immediate information access. Remember back when people didn’t carry cell phones with them 24 hours a day? Or when you had more letters in your mailbox than you had email messages on your computer? Americans today expect immediate access to information and to communication. A patient who would have waited 3 days until they could see their physician about a headache now wants their headache addressed in 3 hours.
  4. Complexity of care. Today’s patients are on more medications and those medications have more side effects. This adds up to more things that can go wrong and more side effects of treatments. This adds up to more worried patients calling their doctor.
  5. Formulary changes. Every January is formulary month for physicians who take care of outpatients. Health insurance companies annually re-negotiate their deals with pharmaceutical companies to get the lowest price on medications. And so Spiriva may be the preferred anti-cholinergic inhaler one year and Incruse the preferred inhaler the next year. In January, patients will get a letter from their insurance company that Spiriva is no longer covered by insurance and they have to call their doctor’s office to get a new prescription for a medication that is covered. The problem is that the letters usually don’t say which equivalent drug is now covered. So the physician either has to call the insurance company or find the new formulary listing for that insurance company on-line to determine that Incruse is now the covered inhaler. I think the hope of the insurance company is that physicians will get tired of the hassle and just discontinue the inhaler prescription.

So, what can you do to reduce the number of phone calls?

  1. Use email. OK, so you can’t exactly use regular email without violating HIPPA laws. But most electronic medical record programs will have encrypted secure messaging with patients. Typically, patients sign into their “patient portal” and then can send messages to their physician’s office. I can type in an answer to a patient’s question in about 30 seconds. If I am returning a call to that same patient for that same questions, it will take me about 3 minutes since there is always a wait time for the patient’s spouse who answers the phone to get the patient on the phone and then the patient inevitably will have “just one more question while I have you on the phone, doc”.
  2. Empower your nurses. In our practice, these messages are routed to a pool of office staff that screen messages. Those that are for appointment scheduling are routed to a scheduler. Those that are for refills are routed to a nurse to tee up the refill order and then route it to the doctor. And, those that are about medical questions are routed to the physician. However, a lot of medical questions can be answered by nurses. For example, a patient with COPD calls and wants to know if he can wear his nasal oxygen cannula in the shower – your nurse can answer that one, you don’t have to.
  3. Optimize medication refills. For maintenance drugs, it should always be 12 refills for 30-day prescriptions and 4 refills for 90-day prescriptions. Pharmacies will honor refills up to 1 year from the original prescription. So, if you give an initial prescription plus 11 refills (a total of 12 30-day prescriptions), that would be 12 x 30 = 360 (five days short of a full year). For patients who return to the office for an annual visit, they are usually coming in at 365 days (or, more often, a week or two after 365 days). Therefore, with 11 refills, they run out of medicine a week or two before their annual visit and have to call to get a refill. By doing 12 refills, they can still get their last refill inside of the 1-year refill limit but the last refill will last them until 390 days from their previous visit, plenty of time to get in for their routine check up and refill encounter without having to also have the the extra phone call to the office for a refill.
  4. Refill medications proactively. Here is where the office staff can really help. Lets say you prescribe hydrocholorothiazide for a patient’s hypertension in December and you give the patient a 90-day supple with 4 refills (390 days worth). But their next annual visit ends up being 11 months later in November because they’ll be wintering in Florida for the next 4 months. They will still have another refill until either the patient or their pharmacist calls your office to request a refill. But, if your office staff check the electronic medical record to determine the number of refills remaining when the patient is in the office in November, they can tee up another year’s worth of refills and eliminate a phone call in January when your patient runs out of medications on the beach in Fort Myers.
  5. Make use of patient information handouts. With most electronic medical records, there is something called an “after visit summary” that is printed out for the patient. It will include information about their visit such as the diagnosis and any changes to the patient’s medications. No matter what you tell them, patients will only remember 3 things. If you tell them 3 things, they will remember 3 things. If you tell them 5 things, they will remember 3 things. So, if you want them to remember all 5 things, add clinical information sheets to the after visit summary. If you just diagnosed a patient with chronic systolic heart failure, include printed information about what the disease is, the need for logging daily weights, sodium restriction, etc. If you are prescribing methotrexate for a patient with rheumatoid arthritis, include information about taking all of the pills at one time once a week, taking folic acid every day, and common side effects of methotrexate to be on the look-out for. These can eliminate the patient getting home, turning to their spouse and asking: “What did he say?” and then eliminating the inevitable phone call asking for a clarification of the doctor’s instructions.
  6. Make test results available. If I order a toothbrush from Amazon.com today, it will show up at my front door tomorrow. If a patient gets a blood test today, they expect to know the results tomorrow. We live in an age of immediate information. If a patient is signed up for a “patient portal” on your electronic medical record, then make sure that test results are released every day – either do it yourself or have the tests auto-released to the patient. We have auto-release of common blood test results such as CBC, chemistry panels, etc. Some of our physicians objected to this for fear that their patients “can’t handle the truth” of their test results and will call the office for every abnormal monocyte count on their CBC. That is not my experience – my patients love it and it reduces the phone calls from patients wanting to know what their annual cholesterol level was. In nearly a year, I’ve only gotten 1 call about an abnormal monocyte count. Also, set expectations. If you order a weird blood test that has to be sent to a specialty laboratory in northern Saskatchewan by dogsled, make sure that the patient knows that the results won’t be back for 3-4 weeks.

Currently in American medicine, we don’t get paid for phone calls – we just get paid for face-to-face office visits. In the future, if we have some form of capitated health care system where we get paid by the size of our patient panels rather than the number of office visits, then phone calls may all of a sudden be an efficient and desirable way of taking care of your patients. Until then, avoidable phone calls can clog up your day with uncompensated time. There are times when our patients truly need to speak with their doctor by phone and at those times, a phone call can equate to better care of the patient. Our challenge is to eliminate the phone calls about issues that could have been handled preemptively with better planning and office structure.

February 19, 2017

Categories
Inpatient Practice Outpatient Practice

I Can’t Get No (patient) Satisfaction

Last week, I attended a breakfast that our medical center put on for physicians ranking in the top 10% nationwide for patient satisfaction. The remarkable thing is that last year, no one invited me to breakfast. Not even close. In fact last year, my patient satisfaction scores were abysmal. Did I change my doctor-patient interactions? No… I’m 58 years old and I don’t change anything very easily. So what happened?

Outpatient satisfaction scores are derived from a series of questions on the CG-CAHPS survey (Clinician and Group – Consumer Assessment of Healthcare Providers and Systems). This is a questionnaire is a cousin of the HCAHPS questionnaire used for hospital satisfaction and it is based on a 1-10 rating scale; only 9’s and 10’s really count so in other words, you have to get an “A+” grade every time. One of the questions is: “In the last 12 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?” The questionnaire is sent to patients one week after they are seen in the office.

In our clinic site, we found that we were not always getting results to patients before they got their CG-CAHPS questionnaire. It is pretty easy when patients are computer-savey and sign up for the “MyChart” account on our electronic medical record, because with a mouse click, I can release blood test results to the patient’s account and they get an email telling them that there are test results available so they should log-in and check their MyChart account. There were three problems:

  1. A lot of the blood tests that I order have to be sent out to reference labs and they can take 2-3 weeks to come back. These results aren’t available when the patients get their CG-CAHPS questionnaire in the mail 7 days after their office visit and so they haven’t been contacted by anyone in my office with lab results.
  2. For some of my patients, our hospital is not in their insurance network so when I order labs, those tests have to be done at another hospital and it can often take many days for me to get results by mail. So, if I see a patient on December 1st and order labs, the patient gets their labs drawn at another hospital on December 5th, and then I get the results in the mail on December 9th, then no one from my office will have called the patient with results on December 7th, when the patient gets the CG-CAHPS survey in the mail because I don’t have the results yet.
  3. Because of the nature of my practice, a lot of my patients are taking immunosuppressive medications that requires monitoring lab tests every 1 or 2 months. Because many of my patients are from out of town, they get their labs drawn at their local doctor’s office or lab and then the results are mailed to me for review. The results are then scanned into our electronic medical record system and my office staff call the patient to tell them that the labs are OK. Many of these patients are used to being able to see all of their test results on their MyChart account when those tests are done at our hospital’s lab. However, scanned PDF files (of outside hospital labs) are not visible on MyChart. These patients were frustrated because they expected that the labs drawn at their primarily care physician’s office, often in a different state than Ohio, would show up on their MyChart account just like those labs from our hospital.

So, what was the solution? Well, all we did was to add a phrase onto the patients printed after-visit-summary (AVS). The AVS is a printed document that we give the patients after their office visit that goes over their medications, future appointments, etc. We added to the AVS:

“If you had blood tests today, many of those blood tests can take up to 3 weeks to complete; our office will contact you when those results are available. If you have an OSU MyChart account, we will release results to your account within 24 of when we receive those results; if you do not have an OSU MyChart account, we will mail you the results and it may take several extra days for you to receive them by mail. If you have blood tests done at non-Ohio State laboratories, these results will not be available on your OSU MyChart account and the results of these tests may take an extra 1-2 weeks to get back, depending on the mail.”

With this simple change to the AVS, I went from having 91.4% of patients rate me with either a 9 or 10, to having 98.1% of patients rate me with either a 9 or a 10. Because there is a tremendous amount of grade inflation with the CG-CAHPS survey, the difference between a 91.4% and a 98.1% is the difference between significantly below average and being in the nationwide top 10th percentile.

The lesson is that patient satisfaction is all about expectations and if we set the expectations, in this case, of when lab tests become available, then we can impact patient satisfaction. My patients didn’t know that when they had an anti-strongyloides antibody, that it takes 3 weeks to get the results back. To the patient, the anti-strongyloides antibody wasn’t any different that a CBC (that results come back in a few hours).

Ultimately, however, medicine is a team effort and even though I’d like to think that my patient satisfaction is high because I’m a good doctor, the reality is that the physician’s patient satisfaction is a reflection of the entire team. So, if you as a physician want to have a high patient satisfaction score, get good nurses, friendly registration staff, responsive housekeeping staff, and plenty of convenient parking at your office. Because the doctor’s patient satisfaction scores really aren’t just about the doctor.

December 11, 2016

Categories
Outpatient Practice

The Obesification of America

prevalence-of-obesity-in-the-usAmericans are obese. We’re more obese than any other country and we’re getting more obese each year. The most recent results of the 2015 National Health Interview Survey were recent released and they paint a picture of the reality of Americans’ health. In 2015, 30.4% of American adults were obese. For those of you unfamiliar with the definitions, overweight is a body mass index (BMI) between 25-30. Obese is a BMI > 30. Obesity can be further stratified into different grades: a BMI 30-35 is grade 1 obesity; a BMI of 35-40 is grade 2 obesity; and a BMI > 40 is grade 3 obesity (also called morbidly obese). It used to be that morbid obesity sufficed as the term for people who were really, really obese. However, because so many people have moved into the morbid obesity range, a new class of obesity had to be added, the super obese, who have a BMI > 50. But if you drill down, there are some interesting findings. For example, Americans in the age range of yours truly, between 40-59 years old, are the most obese people in the U.S. Also, obesity is not a equal opportunity condition: African Americans are more obese than other racial groups.

age-and-race-and-obesitycountry-overweight-caloriesHow does the U.S. stack up compared to other countries? The best information comes from the “Organisation for Economic Cooperation and Development” or OECD. The OECD 2015 health data indicates that the United States is the most overweight of all countries on the planet. 70% of Americans have a BMI in either the overweight category or the obese category. I’ve just selected a few countries in this table but even when you look at all OECD countries, the United States has the highest percentage of its population being overweight. The other way of looking at this is that less than a third of Americans have a normal BMI. This is not something that we should be particularly proud of. One of the reasons that we are so overweight is that we take in too many calories. Here again, Americans lead the world. We consume an average of 3,750 calories per day. The only country whose citizens eat more than the United States is Austria at 3,800; however only 40% of Austrians report being either overweight or obese, presumably because they are more physically active than Americans. The recommended caloric intake for a middle-aged, moderately active adult is 2,000 per day for women and 2,600 per day for men (drop that number by 200 calories if that middle-aged person is sedentary). So we eat too much. Another way of looking at this is that Americans need to drop about 1,500 calories per day. Obesity is due to the confluence of two variables: calories in and calories out. If you want to become obese, you either have to have too many calories going in or you have to have too few calories being burned up. We are taking too many calories in, so what about calories being burned up?

 

physical-activityNot surprisingly, we don’t exercise enough. Although the percentage of Americans who do meet the 2008 Federal guidelines for aerobic and muscle-strengthening exercises during leisure time has been slowly increasing over the past 20 years, only 21% of Americans got enough exercise in 2015 according to the 2015 National Health Interview Survey. This is especially true for older Americans: the older we get, the less we exercise.

diabetes-in-the-usSome people argue that we have placed too much emphasis on obesity and physical exercise. I disagree. Obesity is at the root of so many medical problems that result in healthcare costs, disability, and death: sleep apnea, hypertension, hypercholesterolemia, arthritis, heart disease, stroke, breast cancer, colon cancer, and diabetes. In fact, the prevalence of diabetes over the past 20 years tracks almost perfectly with the prevalence of obesity. Along with diabetes comes foot ulcers, leg amputations, coronary disease, stroke, peripheral neuropathy, renal failure, retinopathy, not to mention the cost of medications like insulin.

 

If you add up all of the bad things that happen when you are obese, the result is that the higher the BMI, the more likely a person is to die. In a study from BMJ (the British Medical Journal) this year, researchers from the United Kingdom reviewed the world’s published literature on the relation of obesity and death and confirmed what has been generally accepted for many years. risk-of-death-by-bmiIf a person is excessively underweight or overweight, their risk of dying goes up. The graph to the right is for all persons but when the researchers broke down the results into smokers and non-smokers as well as persons followed for 5, 10, 15, 20, or 25 years, the curves look the same. The best BMI to have is 22-24. If your BMI is less than 22 (underweight), your risk of death starts to go up. Similarly, if your BMI is above 24 (overweight), your risk of death starts to go up. And if you are morbidly obese, then you are 3 times more likely to die in 25 years compared to a normal weight person.

So what can we as physicians do? First, we need to educate our patients about where their calories are coming from. That half-liter bottle of soda has about 200 calories. A Snickers bar, 215 calories. The large fries at your local fast food restaurant, 500 calories. And if you top those fries off with a medium milk shake, add 670 calories. Then if you finish off your day by splitting a medium pepperoni pizza with someone, that half of a 12-inch pizza cost you 900 calories. Total calorie cost = 2,485. If that same person instead had a diet soda, a couple of fun-sized Snickers bars, small fries, skipped the milk shake, and split a small pepperoni pizza, they would have cut 1,500 calories off of their day.

The other thing that we as physicians can do is to promote aerobic exercise in our patients. It doesn’t really matter whether that is running, swimming, treadmill, elliptical machine, or stationary bike. The best exercise is the one that the person will actually do. You can figure about 300-400 calories burned with 30 minutes doing any of these. Even regular walking for a half-hour burns up about 150 calories.

The irony is that obesity is what keeps me in business. Overweight and obese patient need to see the physician more often, they get sick and use our hospital more often and all of that translates into more medical bills that we get to submit to insurance companies and Medicare. But we as a society can no longer afford obesity. If we really want to keep health care costs down, the best way to do it is to keep our BMI down.

November 16, 2016

Categories
Inpatient Practice Outpatient Practice

You Can’t Get The Flu From A Flu Shot

vaccinationIt is flu shot season and my goal each year is to give more influenza vaccines in my clinic than any of the other pulmonologists. So, I offer it to all of my patients and continue to be amazed at how many of them decline because “Every time I get a flu shot, I end up getting the flu”. There is no live virus in a flu shot so you are just as likely to get the flu from a flu shot as you are likely to get pregnant by taking a birth control pill.

So why are patients so sure that they’ll get an infection from the flu shot. There are two main reasons. First, they may have had some muscle pain at the injection site or even some mild myalgia after a previous injection – this is a reaction to the vaccine and not an infection. If anything, it means that the vaccine is working because your immune system is mounting a response to it.

The other reason patients think that they get the flu from a flu shot is from superstition. The average American gets 2-4 upper respiratory infections (“colds”) per year. Lets just say it averages out to 3 colds per year. That works out to 1 cold every 17 weeks. In other words, statistically, 1 out of 17 patients will get a cold within a week of getting a flu shot purely by chance. Because they associate that cold with the flu shot, they incorrectly deduce that the vaccine caused the cold (which they equate to the flu). By the same argument, 1 out of 17 patients will get a cold within a week of Easter but you don’t hear patients telling you that they got the flu from the Easter bunny.

As it happens, if it wasn’t for influenza, I never would have been born. My grandmother’s first husband was one of the 21 million people who died of the “Spanish” influenza epidemic of 1918-1919. She then remarried to my grandfather so if her first husband hadn’t died of the flu, I wouldn’t be writing this post now. In the United States, about 23,000 people die of influenza each year; some years more and some years fewer, depending on the specific strains that go around that year.

It is particularly important for all healthcare workers to get vaccinated so that they don’t become a vector to transmit influenza to vulnerable patients. A few years ago, I admitted one of my patients with pulmonary fibrosis to the hospital with worsened shortness of breath. On admission, I did a bronchoscopy and sent PCR testing for influenza – it was negative. We determined that he was in heart failure and he improved over the days with diuresis. He lived alone and had no relatives so during his hospital stay, he had no visitors. After about a week, he became suddenly worse with hypoxemia and high fever. I repeated the bronchoscopy and this time, his influenza PCR was positive for influenza A. Based on the incubation period, he had to have acquired his influenza in the hospital. Since he didn’t have any visitors, he had to have acquired it from one of the doctors, nurses, or therapists. He never made it out of the hospital and died of his influenza in our ICU.

So, I’m pretty passionate about getting everyone who works in the hospital vaccinated for influenza each year. I don’t care so much whether they get influenza but I don’t want them transmitting it to a patient who would be more likely to die from it.

October 12, 2016

Categories
Outpatient Practice

340B Programs

pills-2Ohio State is about to expand its 340B program to include a free-standing pharmacy and the outpatient infusion centers. It gave me a chance to brush up on what a 340B program is. The 340B program was created by the federal government in 1992 as a way to provide discounted outpatient drug pricing to healthcare institutions that care for the poor. There are 6 categories of hospitals that are eligible that largely have in common that they are tax-payer funded to care for low-income and uninsured patients:

  1. Disproportionate share hospitals
  2. Children’s hospitals
  3. Cancer hospitals exempt from the prospective payment system
  4. Sole community hospitals
  5. Rural referral centers
  6. Critical access hospitals

In addition, hospitals have to either be state/government-owned, be a private not-for-profit hospital that has been granted governmental powers, or be contracted with the government to provide care to low income patients. In addition to hospitals, there are certain outpatient clinics that are also eligible to participate. As of 2014, there were 2,140 hospitals in the program, 90% of which are either critical access hospitals or disproportionate share hospitals.

The way the program works is that the Health Resources and Services Administration (HRSA) sets the maximum amount that drug companies can charge for outpatient medications – on average this is about a 22.5% discount. Medicare part B covers some outpatient medications (eg, cancer chemotherapy and rheumatoid arthritis infusion drugs); however, the hospitals participating in the 340B programs get paid the same from Medicare part B for these drugs as they would if they were not in a 340B program. Therefore, the hospital stands to make money on 430B drugs. On the other hand, drug manufacturers have to sell the hospitals their drugs at the discounted 340B price and so they would like to limit 340B programs so that they can have a higher profit.  All told, 340B programs save about $4 billion per year in drug costs. There are about 7,000 different drugs in the 340B program.

Ideally, hospitals participating the 340B programs use the increased margin that they get from the 340B programs to help support the care of lower income patients. For example, using profits to pay for rheumatoid arthritis infusion drugs for patients who are low income and have no health insurance and otherwise would not be able to buy these rather expensive medications. The danger is that there is the potential for some hospitals to expand chemotherapy and infusion clinics since they can make a higher margin on the chemotherapy and infusion drugs. Overall, 340B sales account for about 2% of total drug sales in the United States so it is not an enormous amount but 340B pricing is disproportionately affecting high cost chemotherapy and rheumatology biologic medications.

I can see both sides of the argument for the 340B programs but at least for our hospital, it will allow us to treat patients who previously were too poor to be treated for conditions like rheumatoid arthritis and inflammatory bowel disease in the past.

October 5, 2016

Categories
Outpatient Practice

“You Can’t Handle The Truth”: Immediate Test Result Release To Patients

In the movie, A Few Good Men, the climax occurs when a military attorney played by Tom Cruise questions a colonel played by Jack Nicholson during a trial about a murder on a military base and Nicholson famously says: “You can’t handle the truth”. We now have a lot of physicians saying the same thing about releasing lab test results to patients.

Electronic medical records have changed the way we practice medicine in many ways. As physicians, we are focused on how EMRs affect how we practice medicine. But there are also big changes in the way that patients receive medical care and this is often under-appreciated. In this case, it involves who really owns a patient’s medical record: the doctor or the patient?

There is a long history of doctors and hospitals being loath to share medical records with patients or other doctors. Part of it has to do with HIPAA laws and the fear that medical records will fall into the wrong hands. Part if it has to do with the time and expense that it would previously take to photocopy records. Part of it has to do with a suspicion that anyone asking for medical records is planning on using it to judge or sue the physician. But part of it comes from a fear that patients are going to pester us about every minor lab abnormality and create additional work for us explaining insignificant results.

Enter the electronic medical record. We can now organize and disseminate medical information better and more rapidly than ever before. One of the features of EMRs is the ability to communicate with patients, including electronically releasing their test results to them. When we first acquired our electronic medical record, we did not automatically release any test results and the physician had to decide for each test result whether he or she would release the result electronically to the patient. After a few years, we changed it to auto-release basic test results (like chemistry blood tests and CBCs) after 5 days, thus allowing the ordering physician 5 days to review and act on any results prior to the patient seeing them.

Last year, at our James Cancer Hospital, we made blood test results available to inpatients immediately through their electronic medical record. The patients really liked this a great deal and it improved satisfaction scores. Although there was some concern that hospitalists would be “scooped” by patients who often saw their blood test results before the patient, this really didn’t materialize.

This summer, we extended the auto-release to outpatients. It is only for fairly basic lab tests and not for sensitive results like surgical pathology results, radiology results, or genetic tests. Our hope is that we can improve patient satisfaction but the initiative was met by a lot of resistance by some physicians who were concerned about a barrage of phone calls from patients worried about insignificant test results.

Enter the monocyte count. When you order a complete blood count (CBC), you get 19 different results, most of which, you don’t really care about. One of the ones that most physicians care the least about is the monocyte count that rarely means anything significant if it is too high or too low. But if patients see that monocyte count as being abnormally elevated, they can panic because they don’t know if it is important or not. So the fear that was perpetuated by some of our physicians is that they were going to get inundated by panicky phone calls from patients worried about their abnormal monocyte counts.

My own opinion is that the medical records belong to the patient and not the doctor and patients have the right to see their blood test results. Personally, when I see my own doctor, I really like being able to immediately see what my routine cholesterol, hemoglobin A1C, or hemoglobin is when I’m in for my annual check-up. Most patients are a lot more sophisticated today than they were 20 years ago, before the advent of EMRs, and most patient are like me, they want and expect to see their lab results right away.

So far, I’ve only had one patient call about his high monocyte count after hundreds of immediately released lab tests. It is a pretty small price to pay for improved patient satisfaction. Personally, I think patients can handle the truth.

September 27, 2016