Clear Stream

Clear Stream

Friday, May 11, 2018

Noncompliance is bad for you and bad for the Doctor

It's always a challenge to discern why non-compliance occurs. One would think, you made the appointment, you showed up wanting/needing a doctors' help, you took advice, maybe had the test..then nada! I never see some of these patients again. Maybe they moved away. Maybe they got scared by the treatment, or by the fact they actually need to change a behavior in order to overcome illness. Maybe you, as the treating physician, just rubbed them the wrong way.

Communication gaps and expectation gaps are the two factors contributing to noncompliance. I see this popping up over and over. The patient didn't understand, or didn't WANT to understand, the illness or the treatment. Patients seek to apply their mental framework to their condition. "Doc, I know you say the biopsy showed it's a skin cancer, but I know I got bitten by a bug and I want to know how to avoid it".  They want to put things into their schema. They understand cancer is too abstract and scary. It's a struggle to try to get people to see that their own wishes are irrelevant in the aging process or the illness process. Dealing with an elderly population they bring their set-in-stone ways, in addition to their other concomitant medical issues which may make treatments more difficult or prolonged recoveries.

My most recent struggle is a patient I have seen a few times over a 2 year period. He's an octogenarian snowbird, which means he's physically present in my town for 6 months out of the year. He's loaded with skin cancers of the face, being of Scottish ancestry and a lover of golf in subtropical climes. He has numerous scars from skin cancer surgeries over decades of treatment. When he is in town, his life is consumed by golf games, bridge games, going out to lunch, board meetings with his condo association, and Caribbean cruises. It must be a nice life. But these lesions pop up on his nose and face and bleed incessantly and he comes to me for help. He is pleasant, nods his head, I prescribe treatments, I perform biopsies, he leaves my office in agreement, but then he cancels the follow up surgical appointment. The first time it happened I gave him the benefit of the doubt, called him, asked him to reschedule. He comes back 4 months later,  the skin cancer site has healed over and I can't find it, but lo and behold, there's a new one bleeding on his cheek. Out of side out of mind for this patient. If it bleeds it gets his attention. He is seemingly delusional and will not, despite my efforts, see that he has recurrent skin cancers. We've had conversations at every visit about his skin cancer propensity and condition and what to do to get it under control. But then he leaves for Ohio for 6 months; he's gone and it's beyond my efforts.  The most recent visit was a repeat of last years' pattern of behavior and diagnosis, so I advised the patient I cannot be his doctor under the parameters he has unfairly placed on me. Your skin cancer cannot be resolved in 1 visit. It can't be addressed when your priority is your golf game. You have to stay put for a suture removal. You have to pick one place to get care and stick to it. I will no longer be the one. I will no longer waste my time and block other patients' accessibility because we're holding an appointment for you.

I feel sorry that somehow I cannot pierce his delusion and I cannot treat him within the part-time residency /paradigm he has chosen in my sunshine state. Medicine and the human body is not a part time endeavor. It is full time and takes up your full attention and care. I wish there was a screening set of questions I could administer to gauge how motivated a patient is before they're scheduled for an appointment. This is unrealistic but I too can dream.

Friday, April 13, 2018

JCAHO and the Opioid Crisis

I remember in the 1990's when JCAHO and the NEW hospital administrators--oftentimes nurses fired from clinical duties and this was their new gig to avoid unions penalizing the HR hospital division--scolding physicians for withholding pain meds, patients were groaning in pain, you evil inhumane monsters!


20 years later we're in a big fat mess. Not created by any one player, but I would wager the regulatory push to count pain as the "sixth vital sign" along with rewards for prescribing--the latter no longer exists--now as penance they count the free pens a pharmaceutical co. may give out and post this online in compliance with "the Sunshine act" (because sunshine is the best disinfectant!). Too late, the cat is out of the bag. The addicted patients go to the local Kwik Stop convenience and with some hand and eye gestures a drug dealer can appear and proffers heroin from Mexico, for cheap. I see these transactions when I go to to get gas. The a"authorities" know but what is the use? Arrest, bail, back on the street in 10 days.

No one solution will correct this complicated monster. But it will have to start with enforcement of law. If lowly me can identify the drug pushers when I stop for 5 minutes to get gas for my car, so can "the authorities". Get serious about inspecting every single thing that crosses the border--animal, vegetable or mineral. And yes, stop counting pain as a vital sign. Distractions, breathing, ice, Tylenol...that's what my Mom when I was a kid and I hurt myself. We're going to have to start saying NO to pills and NO to JCAHO and NO to patients that whine. And also NO to that truck coming from Guerrero, Mexico.

The 90 day Update

I wrote about this last year. The government mandate that states all physicians' demographic information must be updated every 90 days, even if no changes have occurred.
Now they send smooth and yet slightly threatening emails. Every time the 90 days have elapsed, when I log into the portal a big red box on the top of screen appears. Not enough. Email reminders now clog my inbox like hair on the shower drain. Harass harass harass.

Here's the screenshot:

Updating your profile early helps you avoid distractions

To ensure accuracy for patients, state and federal laws require health plans to check the information in their provider directories every 90 days. That means lots of phone calls, emails, faxes, and letters asking you to update and verify the information your payers have on file…every quarter.

There’s an easy way to cut down on the noise.

Use Availity to verify your profile, and we’ll send that information to all participating payers. You can even download your verified profile, then print or email it to your other payers when they call.

It only takes about 15 minutes to get through the process, because we pre-populate the forms with the information payers already have about your business and physicians. So when something changes, it takes just a few clicks to make sure your payers are updated.

Remember that it’s important to verify and update your profile each quarter, even if nothing has changed.

So log in to the Availity Provider Portal now to verify and update your profile—we’ll update your payers, and you’ll have your day back.

Just another example of the thousand paper cuts that results in the doctor becoming paralyzed.

Saturday, March 24, 2018

the electronic medical records movement must END

Corroborating what practicing physicians have claimed, a recent study published in the Annals of Internal Medicine found that during office hours physicians spent nearly 50 percent of their time on electronic health record (EHR) tasks and desk work.
Researchers concluded that for every hour physicians provide direct clinical face time to patients, nearly two additional hours is spent on EHR and desk work within the clinic day, And, outside office hours, physicians spend another one to two hours of personal time each night doing additional computer and other clerical work.
The time and motion study, led Christine Sinsky, M.D. and her colleagues from the American Medical Association, was funded by the AMA.
The study was based on observations of 57 physicians who work in ambulatory care in four specialties—family medicine, internal medicine, cardiology and orthopedics, in four states, Illinois, New Hampshire, Virginia and Washington. Researchers observed how much time physicians spent on four specific tasks, direct clinical face time, EHR and desk work, administrative tasks and other tasks and self-reported after-hours work.
Researchers observed that during the office day, physicians spent 27 percent of their total time on direct clinical face time with patients and 49.2 percent of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9 percent of the time on direct clinical face time and 37 percent on EHR and desk work. In addition, about one-third of the physicians also completed after-hours diaries and they reported one to two hours of after-hours work each night, devoted mostly to EHR tasks.
In an accompanying editorial published in the Annals of Internal Medicine, Susan Hingle, M.D., from SIU School of Medicine, wrote, “Sinsky and colleagues confirm what many practicing physicians have claimed: Electronic health records, in their current state, occupy a lot of physicians' time and draw attention away from their direct interactions with patients and from their personal lives.”

I m a Luddite. I do not use emr/ehr and I've got all of my medical records on paper. During Hurricane Irma when my office has no electricity and no internet for 8 days, it would have completely impossible to access patient records if I had been using one. My paper charts by a window letting in natural light worked. I was able to see a few patients in those conditions and I was able to diagnose, write notes, and write prescriptions, all on paper. 

ANother patient came to me just last week asking I had received results from her internist. I had not. The patient was seen by her internist for a routine check up and a skin lesion was noted on her leg, which the internist took a culture of said lesion and put the patient on an oral antibiotic. The patient asked the internist to fax those details and results/records to me. The internist, whom I have had interactions with in the past and uses Mod Med, told the patient that due to his being so behind on his electronic notes he wouldn't guarantee that he would be able to get those records to me by fax. That had occurred 10 days prior to my visit with this patient. 
On the day I saw the patient, I had no information about the relevant and important medical encounter because the doctor was too behind on the electronic tasks placed in front of him. 

EMR’s hurt patients and physicians, after all, the Health Information Technology (HIT) company which sold us our EMR system, an expensive EMR used by 35% of the US dermatologists, had assured us that their software and hardware would make our practice more efficient, productive, safer, improve our outcomes and speed compliance with new Federal Regulations to avoid a host of looming Federal penalties and enhance value based care (outcomes/costs). The company only rents access to its software to physicians from the highest reimbursed medical specialties. Their advertisements and marketing state that their EMR is, "Transforming how healthcare information is created, consumed & utilized to increase efficiency & improve outcomes".
Michael Sherling, MD, MBA
Dr. Michael Sherling is the co-founder and Chief Medical and Strategy Officer of Modernizing Medicine. In 2014 Michael, along with Dan Cane, received the U.S. Chamber of Commerce’s Leadership in Healthcare Award.
Michael is responsible for the strategy and medical innovation within Modernizing Medicine’s suite of products and services for dermatology, gastroenterology, ophthalmology, orthopedics, plastic surgery, otolaryngology and urology specialties. With Dan Cane, he has developed novel software solutions for EHR, MIPS and ICD-10 automation.
Under his leadership, Modernizing Medicine has established a user base of over 10,000 providers and raised over $318 million in capital.
Michael is a dynamic speaker and has had the honor of speaking at the 2017 Association of Dermatology Administrators & Managers (ADAM) Annual Meeting, the 2016 Dermatology Entrepreneurship Conference and 2015 Health 2.0 Conference’s “Tools to Fix the Clinical User Experience.”
Michael has been a practicing dermatologist since 2006 and currently practices in a comprehensive skin care dermatology group in Palm Beach County, Florida. Michael also serves on the Advisory Board for the Florida Atlantic University Charles E. Schmidt College of Medicine. Michael is board certified by the American Board of Dermatology. Prior to relocating to Florida, he was the Associate Director of Laser Medicine and Skin Health at Brigham and Women’s Hospital in Boston and served as the Associate Residency Program Director for Harvard Medical School’s Department of Dermatology. He has several publications in peer-reviewed medical literature.
Michael obtained his BS in Biology at Brown University with honors in 1996, his MD from Yale School of Medicine with honors in 2002 and his MBA from Yale School of Management in 2002. He received his clinical training at Harvard Medical School, where he served as chief resident in dermatology
ANOTHER PHYSICIAN STORY: the EHR links to Amazon and sends emails to the patient on the OTC recommended by the physician!!!
" The liability for interfering with optimal outcomes with EHR company linked OTC product purchases is borne solely by the physician, and the revenue for sales of Amazon's OTC products shared solely by the EMR company and Amazon. Who's data is it anyhow, the patients and doctors, the government or the EHR companies? Our EHR Company claims all the chart data is theirs."

Monday, February 13, 2017


THANK YOU AND GODSPEED!!!!!! The bill in the FL House is HB 723 and the Senate Bill number is pending. Fl Rep. Dr. Julio Gonzalez and Sen. Jeff Brandes. are co sponsoring. Here is the bill's text, simple and direct:

HB 723 2017 CODING:
 Page 1 of 3 F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
1 A bill to be entitled
2 An act relating to maintenance of certification;
3 creating ss. 458.3113 and 459.0056, F.S.; providing
4 definitions; providing legislative intent; prohibiting
5 the Boards of Medicine and Osteopathic Medicine,
6 respectively, and the Department of Health, health
7 care facilities, and insurers from requiring certain
8 certifications as conditions of licensure,
9 reimbursement, employment, or admitting privileges;
10 providing construction; providing an effective date.
12 Be It Enacted by the Legislature of the State of Florida:
13 14 Section 1. Section 458.3113, Florida Statutes, is created
15 to read: 16 458.3113 Conditions of licensure, reimbursement,
17 employment, or admitting privileges.—
18 (1) For purposes of this section, the term:
19 (a) "Maintenance of certification" means a periodic
20 testing regimen, proprietary self-assessment requirement, peer
21 evaluation, or other requirement imposed by a recognizing agency
22 approved by the board pursuant to rule 64B8-11.001, Florida
23 Administrative Code.
24 (b) "Recertification" means a subsequent recognition or
25 certification of educational or scholarly achievement beyond
26 initial board certification in a subspecialty by a recognizing
27 agency approved by the board pursuant to rule 64B8-11.001,
28 Florida Administrative Code.
29 (2) It is the intent of the Legislature to further improve
30 the efficiency of the health care market and eliminate
31 unnecessary administrative and regulatory requirements.
32 (3) Notwithstanding any other provision of law, the board,
33 the department, a health care facility licensed under chapter
34 395, or an insurer as defined in s. 624.03 may not require
35 maintenance of certification or recertification as a condition
36 of licensure, reimbursement, employment, or admitting privileges
37 for a physician who practices medicine and has achieved initial
38 board certification in a subspecialty pursuant to this chapter.
39 (4) This section may not be construed to prohibit the
40 board from requiring continuing medical education pursuant to
41 rule 64B8-13.001, Florida Administrative Code.
42 Section 2. Section 459.0056, Florida Statutes, is created
43 to read:
44 459.0056 Conditions of licensure, reimbursement,
45 employment, or admitting privileges.—
46 (1) For purposes of this section, the term:
47 (a) "Maintenance of certification" means a periodic
48 testing regimen, proprietary self-assessment requirement, peer
49 evaluation, or other requirement imposed by a recognizing agency
50 approved by the board pursuant to rule 64B15-14.001
51 Administrative Code.
52 (b) "Recertification" means a subsequent recognition or
53 certification of educational or scholarly achievement beyond
54 initial board certification in a subspecialty by a recognizing
55 agency approved by the board pursuant to rule 64B15-14.001,
56 Florida Administrative Code.
57 (2) It is the intent of the Legislature to further improve
58 the efficiency of the health care market and eliminate
59 unnecessary administrative and regulatory requirements.
60 (3) Notwithstanding any other provision of law, the board,
61 the department, a health care facility licensed under chapter
62 395, or an insurer as defined in s. 624.03 may not require
63 maintenance of certification or recertification as a condition
64 of licensure, reimbursement, employment, or admitting privileges
65 for an osteopathic physician who practices medicine and has
66 achieved initial board certification in a subspecialty pursuant
67 to this chapter.
68 (4) This section may not be construed to prohibit the
69 board from requiring continuing medical education pursuant to
70 rule 64B15-13.001, Florida Administrative Code.
71 Section 3. This act shall take effect July 1, 2017.

The MOC control bill would do the following:
1.       Prohibit MOC for Florida Medical License
2.       Prohibit mandatory MOC participation for membership on hospital medical staff.
3.       Prohibit mandatory MOC participation as condition to be included in Insurance physician panel.


Wednesday, January 4, 2017

Electronic-Everything Will Kill Us

Logged into a payer-sponsored web portal for eligibility and claims yesterday. Big red statement at the top "It's time to update/verify your credentials for Florida Blue". This painful process, even if no practice demographic data has changed, must be repeated every 90 days, they claim due to a mandate from CMS. I didn't bother to look up the actual CMS mandate, why fight every single battle that presents itself? And believe me, there is a potential fight every second of every day in medicine. I presume this is to fight fraud, to verify info, to avoid a cataclysm. The insurance company can point to this and say, "see, we have a system to keep our providers accurately enrolled and processed" but every 90 days seems like overkill. It can certainly be every 180 days, with the caveat that any changes you must log into the portal to report the changes in your demographics--you moved, you got a new last name, a new phone number, etc.... no more inaccurate networks of yesteryear, now we're into the overkill of verifying your existence every 90 days.

What if you're dead? Who logs in then? Just a question.....

After logging in, I then have to log into the verification center using different "provider identification" numbers. Then I get error messages--oops, try again later. So I try again later and after 7 times I'm able to get into my screen for my practice. Then I labor through every sub section that has to be re-verified, clarified, and updated, even though in 90 days I didn't get a new phone, didn't have my license up for a new renewal, didn't change a single thing. I get to the end, then I have to upload government issue photo ID to show that I'm me ( my drivers license). Then I can print and submit this monstrosity after reading a tiny print waiver/disclosure, like the one you get but cannot read every time your iPhone IOS updates. So I click yes and then again, "oops, we are having difficulties, try again later". NOOOOOOOOOOO.

By now 3 hours have elapsed and I'm doing this in between patients, phone calls, and the every day running of a practice. I'm in the red-zone--furious, angry, and frustrated. I call them and try to get a human to see what the trouble is. On hold for 45 mins through different menu punching options. Then I get a person and explain the predicament and nightmare. She blithely tells me, "you're fine, doctor, we got your submission, we've had many phone calls and many problems with the system today". So why didn't you update your website to say so? Why force the issue and have people plodding through it like wet cement? Too bad. We don't care. We don't have the staff. No apologies, no explanations. Shut up doctor, you did it and can move on.

Every 90 days this kafka-esque must be repeated.

Government mandates have paralyzed all of medicine into this horrible nightmare, and I pray every day for the demise of the dysfunctional mess.

Tuesday, December 20, 2016

Adventures in Medical Business

More turmoil, more bad news. I heard from an elderly patient --who had stage IV bladder cancer and seemingly has a permanent foley catheter--that his urologists were all "leaving town". He told me there was an article in the local newspaper last week stating that that Specialists in Urology --a big beautiful practice with a big, beautiful, glossy-white art-deco building, and 7 urologists--is scheduled to close in March 2017. I was alarmed and spurred to do some quick online searches about this.

Here is the local article--

Apparently, the Specialists in Urology group was bought by 21st Century Oncology, and this company was over extended debt-wise and rapidly going broke, failing to make a scheduled loan payment last month. The electronic health records were hacked, and there was a whistleblower act that resulted in heavy fines to Medicare. Bottom line, I smell bad management and bad planning resulting from greed. I think perhaps they were all too quick to jump into things they didn't fully understand, nor fully implement. I'm shocked and saddened to see so much effort and investment go to waste, but most importantly these abandoned patients are left without continuing urologic care. These are mostly prostate cancer and bladder cancer patients, not easy for another doctor to enter the picture without serious hiccups. I'm very disappointed in the government push for EHR and consolidation to help populations and make disease management more efficient--blah blah blah. The reality is that these government led mandates don't thrive well in the deep trench of medicine, much less in a subspecialty like urologic cancers. When the infrastructure and government mandates strangulate innovation and growth and encourage willy-nilly consolidation, it will inevitably end in divorces and unhappy doctors and patients. I don't know what will become of either but I hope they all find a way out of the mess. Like my patient said, "all my doctors left town". He has found a urologist in a town 50 miles with whom he will continue his care.

Upon leaving, he told me he was grateful that after 15 years of being his dermatologist, I'm still here. I told him, so am I.