Monday, March 24, 2014


There are many disruptions in the flow of care these days, especially in the Emergency Department. However, Disruptive has taken on a whole meaning lately, what with the proliferation of mobile and even wearable tech. Today, I cam across this post by Dr. Teresa Wu..

...As you are supervising two of your residents putting in bilateral chest tubes, your eager medical student runs up to the trauma bay with a pair of Google Glass. You are researching ways to incorporate wearable technology like Google Glass into your clinical practice and medical education so you and your medical student have a few pairs of Glass with you at work. You put on Glass and ask your medical student, “What can I help you with?” He informs you that your senior resident wants you to take a look at an ocular ultrasound of a patient he staffed with you a little while ago. He knows you are going to be tied up in the trauma bays for quite some time and wants to know if he can discharge the patient with ophthalmology follow up.

...You turn on Google Glass and link to your senior resident who is also wearing Google Glass while performing the bedside ocular ultrasound (Image 1). Through Glass you can see the ultrasound screen as he views it. What does the B-mode ocular ultrasound demonstrate? What’s the patient’s diagnosis?

Bedside Ultrasound meets Google Glass. Read the whole thing.

Just Wow!

Wednesday, March 12, 2014

EMR: Promises Unfulfilled

Welcome to my nightmare.

My practice is limited to consultative ultrasound in Obstetrics and Gynecology. It's been that way since the mid 1980's. My routine used to be simple. A medical assistant or sonographer would escort a patient into the exam room and take a history, inserting pertinent information on a report form. Patient identifiers would then be entered into the name and data fields on the ultrasound screen. After seeing that the patient was properly set up and doing some preliminary scanning, I would be called in. After asking the patient a few questions and a little small talk, I would then perform the ultrasound exam. I would give the patient a synopsis of my findings sans medicalese and then leave to write a preliminary report. The chart would then go to for transcription and from there to billing. Life was good.

Then I joined a large health system which had incorporated all the 21st century technology, including both an EMR and Ultrasound Reporting software as well, neither of which talk to each other. My routine is considerably different.

Now I am either handed a stack of demographic info or obtain my own demographic info off a computer screen. I then enter this data into another computer screen. This is invariably incomplete as it's usually unclear who referred the patient and to whom the report will be sent. A medical assistant fetches the patient and escorts her into the exam room, but usually I am the one to enter the info into the data field in the ultrasound machine. I am most often the one now who takes patient's history. I also figure what needs to be done and in what order. I then leave the room so the patient can change. After an appropriate interlude, I return and perform the ultrasound examination. I again give the patient a synopsis of my findings and then leave to write my report.

I return to the computer and then finish entering the demographics and some historical data. Because the images are usually not incorporated with a patient's demographics (remember, I couldn't enter that until I spoke with the patient,) I have to "attach the images" to a patient. Then I am ready to write my report. I pull up an image and input data from it into the appropriate field in the report page. I find some fields arranged in a nonintuitive fashion. I entered descriptive information by keyboard now rather than pen as I am now the transcriptionist.

Periodically, I have to launch an additional program to find the appropriate diagnosis codes so the examination I performed can be justified. The present diagnosis code system of about 14,000 codes is set to switch to a whole new system featuring 70,000 codes, which will not make my life any easier. After completing the report and seeing that the exams are entered, the indications are entered and they all are coded, I electronically sign the report and then send it to a network fax driver. Unfortunately, because many of these reports find themselves mysteriously transferred to Altair 4, I also print the report and then walk over to a fax machine to do that myself. In some cases, when the patient's physician is in the same group of offices, I will leave the report with the office staff to be scanned into the EMR. (Remember, I told you the EMR and the reporting software don't talk to each other.

Looking at the two practice systems, I ask myself which system enhances productivity? I used to be a doctor. Now I not only see patients, but I'm a transcriptionist, a biller and a coder as well. And this in a health system with an army of billers and coders. I am not the only practioner with these issues. I can tell you that the increased time subsequent patients wait for their exam because I am dealing with tech issues is not boosting my patient satisfaction scores. But that's a topic for another day.

Sunday, March 9, 2014

Quo Vadis

NJ Medical Society Past President Ralph Kristeller MD gives Fee For Service some historical perspective.

Fee For Service does not operate in a vacuum. It operates in an environment.

My apology in advance for this long email; however, the subject “Fee For Service” urgently requires an airing.

In January 1963, after 8 years of active duty in the US Air Force – the largest HMO in the world at the time, I completed my obligation under the “doctor draft” law. I returned home to Millburn NJ where I rented space in a building almost fully occupied by physicians in solo or 2 or 3 partner practices and opened my office for the solo practice of Internal Medicine. Having entered Military Service the day I graduated from Medical School, I had no experience as a physician in civilian life. An older seasoned Internist gratuitously told me “Ralph it will take you a year to establish your “fee schedule.” How correct he was. Nevertheless I began by charging $5.00 for an office visit, $10.00 for a house call $15.00 for an EKG and $20.00 for a PA and Lateral Chest X-ray.

My cost for doing business included my rent, salary for a part time secretary, interest on my loan, premium payments for disability insurance and premiums for a medical negligence policy. The premium for the negligence policy was less than $100.00 a year.

I applied for membership in my County Medical Society. In order to qualify for full membership I was required to accept call by roster for 2 years. This entailed taking call for the Society’s answering service.

Patients who had an “emergency” and did not have a physician called the County Medical Society and I was required to respond with a house call. There were, as yet, no Emergency Rooms. Other than Blue Cross/Blue Shield, a.k.a the Surgeons Plan because it only covered hospitalization, there were no third party payers. It was a cash and carry system IF the patient had the cash. Otherwise it was Pro Bono.

In addition I applied for membership on the Staffs of two local hospitals. Again there was a requirement for participating in the hospital’s “clinic” which met, as I recall, every 2 weeks. This of course was also Pro Bono.

Since “time is money” Pro Bono must be considered a cost of doing business and therefore factored into my fee schedule. Accordingly, my challenge was: If I set my fees too low I would be in financial difficulty, if I set my fees too high, I lost the patient, the patient’s family and any potential patient referrals. Furthermore, if I failed, in the patient’s opinion, to provide value for my fee, the patient walked across the hall and made an appointment with an older more established physician. Parenthetically, I garnered some patients who walked across the hall to me from my competitor because of patient dissatisfaction. In my view this real world experience is “fee for service” in its pure form.

In 1966 Title XVIII, Medicare, became the law of the land. It promised non interference by government in the practice of medicine and non interference in the fees charged by physicians.

Well, everyone knows what happened and is happening to that promise.

Most importantly failure to keep a promise to the public by government was a little noted C change in the culture of our country and our country continues to pay a very dear price for that change.

To continue - In the 1970’s the Plaintiffs Bar found the deep pockets in negligence litigation.

The cost of doing business for physicians escalated tremendously due to the steep rise in the cost of negligence policy premiums. Paradoxically physicians were conveniently blamed for charging too much for their services. In addition physicians were accused of ordering unnecessary tests in order to increase their incomes. However, what was never brought forth was the astute observation by Mr. Chuck Hardwick when he ran unsuccessfully for Governor of NJ. He stated: “The power to sue is the power to terrorize.” Extra testing as a defense against terror by rational physicians was mischaracterized as “unnecessary testing” by politicians for their own self interest. It has been estimated that the added cost to our current health care system, due to “mal practice” expenses, is 50 Billion dollars a year. For politicians the medical tort system is the third rail and they refuse to touch the issue. However, unassailable studies by Professor Localio et al have shown that our medical tort system does almost nothing to compensate truly injured patients. Meanwhile for the country it creates an economic disaster.

By manipulating the words, and thereby poisoning minds, politicians captured public attention and focused the debate on the need to control cost, implying that physician fees are the main culprit.

However, the facts are that Physicians have been under price control ever since the promise of non interference by Medicare was broken. More importantly there has been no attempt to control practice costs which are the main ingredient in physician fees. Rather it has been politically profitable to blame physicians rather than deal with the core issues that contribute to the real cost of our healthcare system.

In short the “Victims (physicians) Are Blamed For the Crime.”, quality of medical care, as defined in AMA policy, continues to deteriorate, the lobbyists and the politicians continue their lucrative careers and the country is, according to the polls, going in the wrong direction.

Finally: Two thoughts come to mind:

"No one can make you feel inferior without your consent." Eleanor Roosevelt

More to the point:

Ann Landers adage: "If you act like a doormat, don’t be surprised when people wipe their feet on you."

Ralph Kristeller

Well said, Dr. Kristeller.

Tuesday, March 4, 2014

Finding The Cancer In A Haystack

March is UK Ovarian Cancer Awareness Month. (It's September in the US.) This year, approximately 14,000 women will be killed by this dread disease. While screening tests have reduced the death rates from other cancer, the same cannot be said for ovarian ca ncer. The search for the appropriate screening regimen for most women remains elusive.

Newer technologies may yet impact on the detection rate. Recently, investigators from MD Anderson Cancer Center reported on a new wrinkle in a commonly utilized blood test, the CA125. What they found was that rather than a specific trigger value, the rate of change over time is a better predictor of risk.

While ovarian cancer is thought to be a "silent killer," this may be a misconception. Another development is a report that Symptom Triggered Screening may reveal many women with early stages of the disease whi le reduce unnecessary surgeries. Anderson et al found that frequent pelvic or abdominal pain, bloating, or feeling of fullness while/after eating of relatively recent onset warrants further investigation and may be life-saving. CA125 blood test and a vaginal ultrasound (a regular bimanual pelvic exam is less able to find abnormalities) would be reasonable diagnostic investigations. Again, often it is the rate of change of CA125 that is most diagnostic.

Some women with BRCA1 gene mutations are at extremely high risk and should consider Risk Reductive Surgery.

There are also reports that an aspirin a day can keep the oncologist away. Daily low dose aspirin may reduce ovarian cancer risk by up to 20&.

Hopefully one day soon, we will make real progress in reducing the toll of ovarian cancer.

For more info, feel free to leave a message in the comments section. To schedule an appointment for an ultrasound in the NYC are, call (718) 925-6277. We are all in this together.