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Curbside Consult with Dr. Jayne 11/9/15

November 9, 2015 Dr. Jayne 1 Comment


My parents are quite the travelers. Although they’ve avoided most illnesses on the road, they did wind up recently at a walk-in clinic in rural Australia. The facility is staffed by a rotating slate of physicians who fly in periodically. They were eager to be seen before the doctor flew out.

Given my career with electronic health records, my father thought I’d get a kick out of his visit note. It’s a grand total of four pages (two which really matter) and features such complex notations as “unwell” and “sinusitis.”

The physician note is the haiku of clinical documentation and made me wonder what kind of job satisfaction this physician has related to topics such as “administrative simplification” and “regulatory documentation.” I think it’s pretty good since he doesn’t appear to have too concerned with gathering bullet points or capturing all the screenings that we’re required to document on patients in the US regardless of their presenting problem.

I’m betting the form was captured electronically since he was discharged with the original document. Talk about OpenNotes and transparency for patients. It reminded me of a note I saw in a chart when I first went into practice. We had purchased a retiring physician’s charts and it said simply: “Sore throat – PCN – $10.” You can bet the patient paid at the checkout desk and that the note was complete before the patient left the room. It may not be interoperable, but it certainly is elegant in its simplicity.

My mother also had a visit. Both were treated appropriately for their conditions and with low-cost generic medications. It’s interesting to hear about healthcare delivery in its purest form. Although their situations were low complexity and low risk, not every visit needs to have a full-court documentation press. There may be times where minimalist documentation is appropriate, but unfortunately our systems don’t support that. Even with the push for value-based care, I don’t see any payers loosening their documentation requirements.

It was with that situation in mind that I headed out this morning to work with a practice on a population health initiative. They’re a mid-sized primary care group that’s already running pretty lean, but they want to try to figure out how to better reach patients who need preventive services or who may have missed follow up steps on their chronic conditions.

Although it’s really a productivity and optimization project that doesn’t necessarily need clinical oversight, practices like to hire me because I’m an actual doctor. They feel like I have a better understanding of their needs because I’ve been a practice owner myself and have been in their position. Sometimes it makes things difficult, though, because I see clinical issues that are outside the scope of my current role but still need to be addressed.

Today was one of those days. While I was shadowing the triage nurse to get an idea of her workload and the flow of her day, she was interrupted by a call from a patient’s family member. Apparently the 87-year-old patient has been having low blood sugars after recently being placed on diabetes medication. Her sugar has been less than 50 several times in the last few weeks, which typically isn’t compatible with good brain function and puts her at risk of falls and other serious complications. As she was talking to the family and later the patient, I was watching over her shoulder to see the patient’s lab values.

Hemoglobin A1c is a marker of longer-term blood sugar control. Hers was barely elevated even before she was started on medications. She immediately had low sugars when starting drug therapy, so the physician had changed her dosing to three days a week and she was still having issues. I started wondering why in the world this doc had her on medication to begin with. With many diabetic patients, if you can keep them at a reasonable level with just diet and exercise, you try to avoid medications. Her near-normal value was certainly reasonable by most physician’s standards.

The whole goal of keeping people’s sugars in the normal range is to prevent the long-term complications of diabetes. I didn’t see any complicating diagnoses on the patient’s chart – no kidney disease, nerve damage, eye problems, etc. There’s plenty of literature that shows that especially in older patients, it’s more risky to try to keep blood sugar control too tight. Once the patient was scheduled for an appointment, I gently queried the nurse about the physician’s typical treatment of these kinds of patients.

She mentioned that he is “obsessed” with his performance scores and this isn’t the first time she’s dealt with this issue. Apparently he’s worried about “being dinged” in reporting and “losing his star” with a payer. It made me immediately remember the old adage from medical school about needing to “treat the patient and not the numbers,” which means to consider the person in front of you and not just their labs or the data. I asked her if they knew how to exclude these kinds of patients from clinical reporting if there were good reasons that they shouldn’t be treated in a certain way or managed to a certain level.

She hadn’t heard of the ability to do this in their EHR, so we asked a couple of other nurses and none of them knew it either. Excluding the patient from reporting on this particular parameter would prevent the physician from being penalized for less-tight blood sugar control in this patient who clearly should not be managed so aggressively. By lunch time, we were able to grab a few minutes with the physician in question and he didn’t know about the ability to exclude, either.

Although he was initially offended and felt that I was questioning his care, he realized that I was not only trying to help the patient, but to help him be able to practice in a more rational patient-centric manner without running afoul of the scorecards that we’re all slaves to now. Excluding patients such as this one may take a few more clicks, but they’re well worth it. Although Big Data can provide impressive insights and help us change how we practice, we need to make sure we’re changing in the right way and for the right reasons.

How has Big Data impacted your care delivery system? Email me.

Email Dr. Jayne.

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