Joint Commission Inspection and Data Entry Duty for the Doctors

I received an email from our hospital Accreditation Coordinator/Quality Coordinator in a manner that wasn’t clear if it was directed to me personally or if it was sent to the entire medical staff.  It said that she was reviewing the Joint Commission Accreditation of Hospitals recent survey which found that the charts did a poor job of reflecting the patient’s “Code Status”.  The institution only received a 40% rating.

Some patients were listed as “Do Not Resuscitate” (DNR) but did not have the yellow State of Florida DNR Form on the chart.  Some charts had the DNR form but the physician, in a progress note, had incorrectly indicated that if the patient’s heart stopped beating, or they stopped breathing, that the patient was in fact a “Full Code.”   Of the 25 charts reviewed only ten were in full compliance.

For some reason I took this email very personally.  In my practice I take the time to discuss end of life issues with all my patients who are at an age, or have issues, that make one believe they may face a catastrophic cardio- respiratory arrest in the future.  When I have the discussion with the patient and family, I present them with a large yellow State of Florida DNR form. The large top half and small detachable bottom half are identical. The patient is supposed to fill both out, with the physician signing both.  We photo copy the form and scan it into the patient chart while listing DNR Status on the electronic health record face sheet for all to see.  The patient is supposed to place the large yellow upper half on their refrigerator while carrying the smaller wallet sized version in their wallet or purse.

Most of my patients get to the hospital through the emergency department by self-referral. Sometimes they call us first but most times they call 911 or go themselves.  Most situations involve unexpected falls and trauma or pain from a chronic source.

When I am called by the ER staff the patient has been registered in, insurance has been checked, medications have been reviewed, as have allergies to medication, and the patient has been evaluated by nurses and physicians.  The patient’s record is a mix of paper documents and electronic health records.  The hospital recently instituted a new electronic health record system with inadequate staff training and support (in my opinion) with decisions for financial reasons.  The result is that most clinicians are constantly searching for information and not quite sure where all of it is.  There is still a loose leaf binder type shell for some daily paper information such as the EKG rhythm strips created on the telemetry monitors.  Where a State of Florida DNR form is kept is anyone’s guess.  I took the electronic health record training course on line and the two in person events. At no time did they discuss entering a code status or show us how to enter this data.

It seems to me that the question of a patients “Code status” is something that should be asked at registration in the ER and at elective pre admission. All patients should be considered a full and complete code unless they say otherwise and can produce the documentation needed. If they are not carrying the documents with them then the document should be re-executed and signed at the registration desk by the patient or their legal health care surrogate. When their physician shows up to admit them the document should be on the chart, filled out for us to see.  I can access my office patient files at the emergency department from my iPad but, due to lack of interoperability between electronic health records in the office and in the hospital, I have no way to print out the document from my office electronic health record while I am at the hospital.

If end of life issues have not been discussed with the patient prior to hospitalization, I have no problem beginning the conversation when the medical condition they are there with has been addressed and stabilized.

It turns out that the email was addressed to the entire medical staff and not directed at me alone.  None of the 25 charts reviewed by JCAHO were mine.  If administration wishes to fix the problem it needs to make sure its employed clerical staff are trained to ask the right questions and list the answers where the doctors and nurses can easily see them and interpret them and act on them if necessary. Don’t ask caregivers to be data entry clerks for JCAHO or anyone else.

Leave us free to provide health care.

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“They Paved Paradise, Put in a Parking Lot”

My local hospital has been petitioning the local city zoning board for permission to build an on-site parking garage for years now.  The city zoning board is very strict about the height of buildings and has turned the requests down repeatedly.

This past fall, the hospital administration announced that it needed a capital partner to expand and stay solvent.  Most of the members of the hospital medical staff have absolutely no idea if this is true and accurate or not.  We do know that several weeks after agreeing to a relationship with a well-respected health care system as a capital partner, they received permission to build that garage.

Construction is set to begin in March so it was no surprise to receive a three page email announcement that the physician hospital parking has been moved from adjacent to the hospital to an area that will make it significantly easier for me to get my daily 10,000 steps in. The construction will take a year. Florida’s sudden onset of torrential downpours will present a challenge but, that’s what umbrellas are for.

I bring this up after making rounds on my affluent patient, whose hospital identification information identifies him as a VIP Benefactor with a yellow star, upstairs in the spectacular VIP section known as the Rockwell Suites.  The operators have gotten used to us staff members calling in and asking the operator to connect us to the nursing station at the Rock and Roll Suites.

His room is the size of three to four rooms with dark wood paneled floors and walls. There are three big screen TVs in this room along with two computer screens. The floor has its own chef available to make a meal for a patient or family member anytime of the day or night.  There is a surcharge for this type of room not covered by insurance.

When I left this patient’s room, and had adjusted his medications at the nursing station, I went downstairs to the general medical telemetry floor.  My patient on that floor also is a benefactor but is in a semiprivate room being evaluated for a fainting episode.  I reached up behind his bed for a blood pressure cuff to check his blood pressure in various positions and there was none. I walked out to the nursing desk and asked the charge nurse for a blood pressure cuff and, after five minutes of going from room to room, she found one that didn’t hold the pressure load and was not working very well.   A digital one was finally located so I could measure the patient’s blood pressure myself.

My community hospital was built by neighbors and philanthropic donations after two young children died of a poison ingestion and there was no local hospital to bring them to. It was controlled by a lay community board, a community medical staff that represented the patient’s through the physician staff and a separate administration.  Addition of new doctors to the staff required the approval of a lay community council that first looked at the need for that specialty based on the population and the number of existing doctors already here practicing that specialty.  They were concerned that too many doctors would lead to many unnecessary tests because everyone needed to generate income.

That community hospital is now a “regional “hospital with a board filled by CEOs of Fortune 500 companies and doctors who are employed by the hospital. The pediatrics wing has been closed down because it lost money.  There is no geriatrics wing despite a plethora of senior citizens. There is little or no relationship with the student health programs at the two local universities.  There are no blood pressure cuffs in most rooms and no otoscopes or ophthalmoscopes in most rooms in the emergency department.  But, there are three big screen TVs in the Rock and Roll Suites and a parking garage in the works.

I wonder who now represents the health and medical needs of our community?

How to Deal With Pharmaceutical Product Recalls

In the last six months there have been numerous products voluntarily recalled because in the manufacturing process a possible human carcinogen was inadvertently produced as part of a new modernization of their production product. The important things to remember is that the product MAY have been produced and that the element produced MAY be a human carcinogen.

Mass media has used this information to inaccurately heighten the fear of consumers and sell more newspapers, magazines and air time. The risk, if there is a risk at all, is quite small.

The recalls all involve generic blood pressure medications manufactured outside the United States of America. Many of the factories have not been inspected in years because the US public’s thirst for “small government” has led to a decimation of funding for the federal agencies assigned to train inspectors and send them out to monitor manufacturing plants.

If you believe your medication has been recalled I suggest these steps:

  1. DO NOT ABRUBPTLY STOP TAKING YOUR MEDICATION.
  2. CALL YOUR PHARMACY THAT SOLD YOU THE PRODUCT AND ASK THEM IF THE PARTICULAR PRODUCT YOU HAVE HAS BEEN RECALLED. Most of these products come from multiple manufacturers and they may have a supply of non-recalled medication.
  3. If your supply has been recalled ask the pharmacy to replace it with non-tainted product. If they have a replacement product then call your prescribing doctor to seek a similar or alternative product.
  4. DO NOT STOP THE MEDICATION UNTIL YOU SPEAK TO YOUR PRESCRIBING PHYSICIAN. The risk of contracting cancer from taking these pills is minimal. The risk of getting ill from inappropriate worry and or concern is higher than the risk of cancer from these products.

Winter is the Season for Upper Respiratory Tract Infections and Influenza

It’s the season for winter viral upper respiratory tract system infections. It is also influenza and influenza- like illness season.

Winter brings crowds of people indoors together and holiday travel places crowds together in indoor areas as well. These viral illnesses are transmissible by hand to mouth transmission and airborne particle transmission with coughing. The viral particles can live with minimal water on surfaces for long enough periods of time to infect patients who unknowingly touch a foreign surface and bring their hands up to their mouths. Hand washing frequently is an essential part of preventing the transmission of these diseases. Common courtesy such as covering your mouth when you sneeze or cough and not coming in close contact with others when ill is essential.

Research has shown that consuming an extra 500 mg a day of Vitamin C can prevent colds and reduce the intensity of a cold if you catch one. You must take the Vitamin C all the time and in advance of exposure. Waiting until you have symptoms has no positive effect. Viral upper respiratory tract infections usually include fatigue, runny nose (coryza), sore throat (less than 90 % of adult sore throats are not a strep throat).

If you have been around a sick child age 2-7 who has a fever, swollen neck glands and an exudative sore throat your chances of having a strep throat are increased. Fever is usually low grade, less than 101, and short lived. Very often patients develop viral inflammation of the conjunctiva or conjunctivitis. While this is very contagious to others, it is self-limited and rarely requires intervention or treatment.

Caring for a cold involves listening to your body and practicing common sense solutions. Rest if tired. Don’t go to the gym and workout if you feel ill. If you insist on going, warm up slowly and thoroughly and, if you do not feel well, stop the workout.

Sore throat can be treated with lozenges. Warm fluids including tea and honey (honey is antimicrobial and anti-viral), chicken soup, saline nasal spray for congestion and acetaminophen for aches and pains or fever are mainstays of treatment. Over the counter cough medications like guaifenisin help.

Some of the viruses affect your gastrointestinal tract causing cramps and diarrhea. Nausea and vomiting are sometimes present as well. The key is to put your bowel to rest, stay hydrated and avoid contaminating or infecting others. Clear liquids, ice chips, shaved ices, Italian ices or juice pops will keep you hydrated. A whiff of an alcohol swab will relieve the nausea as well. If you are having trouble keeping food or fluids down call your doctor. If you are taking prescription medications, call your doctor and see which ones, if any, you can take a drug holiday from until you are better.

Influenza is more severe. It is almost always accompanied by fever and aches and pains. Prevention involves taking a seasonal flu shot. Flu shots are effective in keeping individuals out of the hospital from complications of influenza. They are not perfect but far better than no prevention. If you run a fever of 100.8 or higher, and ache all over, call your physician. An influenza nasal swab can confirm influenza A and B 70 % of the time.

The new molecular test which can provide results in under an hour is far more accurate but not available at most urgent care or walk in centers or physician offices. Immediate treatment with Osetamivir (Tamiflu) and the newer Peramivir are effective at reducing the duration and intensity of the infection if started early. Hydration with clear fluids, rest, acetaminophen or anti-inflammatories for fever in adults 101 or greater and rest is the mainstay of treatment. Prolonged fever or respiratory distress requires immediate medical attention. Call your doctor immediately.

I get asked frequently for a way to speed up the healing. “My children are coming down to visit. We have a cruise planned. I am flying in 48 hours on business.”  I am certainly sympathetic but these illnesses need to run their course. They are not interested in our personal or professional schedule and everyone you come in contact with is a potential new victim. If you are congested in the nose or throat, and or sinuses, then travelling by plane is putting you at risk of severe pain and damage to your ear drum. See your doctor first. Patients and pilots with nasal congestion are advised not to fly for seven to ten days for just this reason.

If you have multiple chronic illnesses including heart disease, lung disease, kidney disease and you run a fever or feel miserable then call your doctor and make arrangements to be seen. It will not necessarily speed up the healing but it will identify who actually requires antibiotics and additional follow up and tests and who can let nature take its course.

Doctors of Pharmacy and Their Role in the Health Care Team

My patient, a mental health professional, was sent for an MRI of her hips and back by her orthopedic surgeon. He was in surgery when she called him for an antianxiety medication to help her get through her claustrophobia in the MRI machine.

She waited seven hours for a response and when a repeat phone call resulted in no response she called me. I asked her if she was driving herself to or from the procedure and she answered no that her husband was taking her. I phoned in a small supply of a longer acting antianxiety medication called lorazepam 0.5 mg one tablet 30 minutes prior to the procedure. It was called in at 4:00 p.m. after we first accessed the in-state narcotic prescribing line Eforsce to make sure our patient was not pill or doctor shopping.

I received a phone call at 9:00 p.m. that evening from the patient who was at the pharmacy saying they didn’t have lorazepam in stock. It was unclear to me why, if they did not have the medication in stock, no one was responsible enough to call me and request an alternative prescription? I called the pharmacy in response to the patient calling me and ordered another product. However, they did not respond to my question “Why didn’t you call me if the medicine I ordered was not available?”

This week a 63 year old woman with three days of painful urination came to my office. Her urine suggested an infection. I called her pharmacy to phone in a prescription for ampicillin until her culture and sensitivity results were known. The pharmacist said she was too busy to take the call and asked me to leave a message. I waited for the beep and left the message. Thirty six hours later I received a fax to my office telling me that they were out of ampicillin and did not offer an alternative. I immediately called the pharmacy, furious at the delay and prescribed an alternative medication. Once again, if they did not have the ampicillin then why did it take them 36 hours to inform the patient or me? Why was this done by facsimile and not a phone call? The potential for complications of an untreated gram negative urine infection is frightening and life threatening. This should never occur. Then again why isn’t a common inexpensive antibiotic available in South Florida?

This is not very different than the blood pressure medicine Valsartan recall due to production induced impurities. When the recall was announced, I searched my computer and contacted my patients taking this medication to discuss options. For those demented and cognitively impaired patients I first called the pharmacy to ask if their supply was part of the recall. Much to my surprise much of it was under recall but the pharmacy had no intention and felt no professional responsibility to inform the customers who they had sold the tainted product to.

Pharmacists continually stress their professionalism as part of the health care team. These are three recent local examples of their need for improvement.

The Florida Legislature and Florida Medical Association Making Docs the Fall Guys

I wrote and mailed my annual $250 check to the Newborn Injury Compensation Act (NICA) fund today. In 1982-83, when there was a medical malpractice crisis and no physician could get insurance to practice, the Florida Medical Association (FMA) cut a deal with the trial lawyers and our elected officials to form NICA. Every physician, regardless of specialty, is required to pay $250 annually into this fund to cover the cost of injuries to newborns. Obstetricians pay $5,000 annually.

In exchange for making the social problems of the state the responsibility of Florida physicians alone, the legislature passed some changes to the medical malpractice laws which encouraged insurers to return to and start writing policies in Florida. Isn’t it time for the State of Florida and its citizens to assume their responsibility for providing reproductive education and prenatal opportunities to women of child bearing age nearly 40 years later? Why does it remain my responsibility as a physician to continue to fund this entity? The FMA thinks it is still a good deal and will not discuss lobbying for a change.

Recently I attended one of many continuing education courses mandated by the elected officials in Tallahassee. It was on prevention of medical errors. It’s the same course I took two years ago and two years before that. Most of the errors are surgical and do not apply to me. The others are communication issues.

I have proposed over and over to my hospital’s chief medical officer and medical staff that we form a medical staff communication committee to facilitate doctor to doctor, and doctor to staff, communication to improve patient safety and care. Time after time they turn a deaf ear to the suggestion yet they host the medical error meeting yearly.

They also host the Domestic Violence lecture yearly. It too is mandatory for license renewal in Florida. The same message is delivered every year. “If the assault is made with a knife or gun call the police because they can do something. If a weapon is not involved your only option is to recommend counseling and safe shelters.” The Legislature has done nothing to toughen domestic abuse laws but they make us sit through the lecture every two years.

I have the same message for the legislature, the FMA and the Florida Board of Medicine, “You can kiss my grits!”

Wasting Taxpayers Money, Medicare Advantage and the RAC’s

My wife and I try to catch up on TV shows on Thursday evenings. We sit down with a cup of decaffeinated coffee on the couch together petting our dogs and watching mindless entertainment after a day at work. Now that the election is over, almost every commercial in my South Florida market is an advertisement for a Medicare Advantage Health Plan. We are nearing the completion of the “open enrollment” period between October 15 – December 7 when senior citizens can change their Medicare Part D Prescription Plan to one that covers their formulary of medicines and they can choose to leave the Medicare system and join a private health plan for a capitated Medicare Advantage Plan. These plans were initiated by the Center for Medicare Services (CMS) as a way to save money on the health care of seniors. The theory was that if they offered a product with a fixed monthly and yearly cost budgeting would be simpler and at least they would know what they are paying.

These programs are run by private insurance companies such as Humana, Blue Cross Blue Shield, and Aetna. Over the years, research has shown that they now cost the Medicare system more money per year, per patient, than the traditional Medicare system. The private insurers are probably making a great profit on this program because the money and energy spent on advertising to attract patients is relentless. I have been receiving multiple daily promotional letters in the mail for weeks now. Full page ads are run daily in major newspapers and magazines. Prime time television is filled with expensive ads with noteworthy spokespersons like basketball hall of famer Ervin “Magic” Johnson in addition to actors, actresses and former elected officials.

The insurers make their money by rationing and denying care provided by doctors and hospitals which agree to see patients in volume for a discounted fee. Patients have no deductibles; have no out-of-pocket expenses for physician care or generic pharmaceutical products if they stay in network. If they happen to get sick out of the service area, coverage is spotty and varies by program with the advice truly being “buyer beware.”

It seems to me that if these programs are actually more expensive per patient than traditional Medicare then why is CMS continuing them and allowing the millions of dollars spent on advertising to attract patients to continue? The information they need to choose a plan is available on the easy to use http://www.Medicare.gov website at no cost.

I open some non-critical advertisement mail as well. One letter from the Center for Medicare Services addressed to me personally as a patient, not as a physician, was extremely interesting. In December 2014 I was involved in a serious auto accident with my vehicle totally damaged due to the negligence of another driver. I was taken by ambulance to the local emergency room, examined, treated and released. At the time I was 64 years old and several months short of being eligible for Medicare. My auto insurance paid my medical bills. My private insurer Blue Cross Blue Shield was not billed.

The letter from CMS was a form letter saying that a claim from December 2014 had been investigated by them and although no payment was made on this claim, which was paid by Traveler’s Insurance (my auto insurer), they were now referring it to the Recovery and Audit Division for further investigation. The threatening nature of the letter suggested that if I was compensated by Medicare for this claim I would be required to pay back the money with interest and penalties. Considering I was not yet on Medicare, and considering the charges were billed by the local hospital health system, I am not quite sure why the letter was generated and forwarded to me?

Once again a government agency is spending taxpayer money on a frivolous item. How many more of these letters go out yearly at our expense?

The second letter I opened was from Social Security. It said that since I was still working and generating income, my wife and I would be required to each pay an additional fee per month for our Medicare health insurance and for our Medicare Part D prescription drug plan. This is in addition to the tax on my salary that goes directly to Medicare. I have been paying this tax on each paycheck since I started working at age 14 (I am now approaching 69). I read this letter just after hearing one of our elected officials to the Senate refer to Medicare as an “entitlement program.”

My Medicare bills now approach what private insurers charge patients for health insurance. I paid into this system for 51 years before I became eligible to use it. I hardly think the Medicare system is an entitlement.