EPIC Go-Live Day! And a prayer for wisdom…

Some dear friends of mine, at Busy Community Hospital, are having a momentous day.  Today is the ‘Go-Live’ for their brand new, shiny EPIC EMR.

For those of you outside the hallowed, creaky halls of medicine, EPIC is one of the most widely used electronic medical records systems in America.  It’s big, it’s expensive, it captures lots of data, integrates ER’s, hospitals, clinics, labs and everything else.  (Probably your cat’s shot records too.)

EPIC is also a company highly connected to the current administration; big donors to the President.  FYI.

The problem isn’t what you get out of it, it’s the cumbersome way you have to put it in.  In my opinion, for what that’s worth, EPIC is not intuitive. It takes a long time to learn to use it well.  I have never used it in a situation where it could be fully customized, but I’m told that makes it easier.  And admittedly, some docs and nurses truly love EPIC and are at peace with it.  I suspect they have implanted brain chips or have undergone some brain-washing.

https://giphy.com/gifs/zoolander-ac38RqTgQXYAM

Typically EPIC instruction occurs over weeks, as it has for my friends.  The first time I used it was in a busy urgent care, which was part of a large medical system.  And I learned it over one hour. On the Go-Live day.  So I’m sympathetic.

Thus, I have a prayer for those in the belly of the beast right now:

A Go-Live Prayer for those with new EMR systems.

Lord, maker of electrons and human brains, help us as we use this computer system, which You, Sovereign over the Universe, clearly saw coming and didn’t stop.

Thank you that suffering draws us to you.

Thank you for jobs, even on bad days.

Forgive us for the unnecessarily profane things we have said, or will say, about this process.

As we go forward, we implore you:

Let our tech support fly to us on wings of eagles and know what to do.

May our passwords and logons be up to date.

Protect us from the dreaded ‘Ticket’ submitted to help us.

May our data be saved, not lost.

Let the things we order be the things we have.

Shield us from power loss, power surge, virus and idiots tinkering with the system.

Give our patients patience to understand why everything takes three hours longer.

And may our prescriptions actually go to the pharmacy.

Keep us from rage and tirades.

Protect the screens from our angry fists.

May everyone go home no more than two or three hours late.

And keep our patients, and sanity, intact.

Great physician, great programmer, heal our computers.

Amen

 

 

 

 

 

 

A dark union: EMR meets EMTALA

Ah, EMTALA! The revered ‘Emergency Medical Treatment and Active Labor Act!’ It’s one of those things which is like a nursery rhyme to emergency medicine folks like me. We’ve heard about it from the infancy of our training.  ‘And then the bad doctor sent the poor lady to another hospital because she couldn’t pay!  And the King came and crucified him for doing it!’  The end.

EMTALA, for the uninitiated, is a federal law which ensures that we don’t turn people away from the ER because of finances, and also keeps us from transferring people to other hospitals without that hospital’s agreement.  It also exists to guarantee that we stabilize them as much as possible before they go.

I’ve said before, and always will, it was a good idea.  But like many laws, it was subject to the law of unintended consequences.  For instance, being forced to see lots and lots of people (who may not really be that sick), and do it for free, has huffed, and puffed and blown the hospital and trauma center down on too many occasions.  But that’s not my point here.

My point is that when EMTALA forms meet electronic medical records, chaos can ensue.

Allow me to illustrate:  This is a standard EMTALA form.  Check, check, check, sign.  It takes a busy physician less than a minute, and the nurses a few more since they have to call the other hospital and record times, etc.  This has worked well for a very, very long time.

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Enter EMR.  This is the procedure for doing an EMTALA form at Tiny Memorial Hospital, which has been enchanted by the dark Lord Cerner.  Mind you, I’m sure the ‘powers that be’ feel that this is a perfectly wonderful way to do the form.  Indeed, it captures lots of information and stores it in the system.  But two facts remain:  first, the people who designed the system generally work at Large Urban Hospital, which owns Tiny Memorial.  They don’t transfer things out very often.  They receive things.  Second, most of the patients being transferred are going within the system.  All the data is on the EMR, and it isn’t as if they’re going to some strange facility far, far away.

This, children, is the EMR based procedure (on a cheat sheet developed by a frustrated and confused provider):

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Not long ago my team worked a cardiac arrest at Tiny Memorial, with a successful return of cardiac activity.  Given our size and staffing, it took pretty much all of the staff available and nothing moved for a while.  A helicopter whisked our patient away.

Of all the things we did; drag her out of the car, do CPR, start IV’s, intubate, talk with family, chart, arrange transfer, nothing was as complicated or frustrating as this process to complete the EMTALA form.  In the end, I still got it wrong somehow.

Mind you, I never violated the spirit of the law in any way. She was treated, stabilized (to the extent of our ability) and sent away to a receiving hospital with the capacity to care for her.

I don’t want to impugn the motives of those who developed this.  I’m sure they were trying their best.  But if you don’t use it, you can’t see how hard it is. And you also can’t see how much time it takes in a place with limited resources and staff.

So please, folks, let’s use technology to simplify, not make things more complicated!  And let’s remember that charting isn’t the same as doing the right thing. And sometimes, doing the right thing isn’t perfectly reflected in the chart.

But paper or electrons, it’s still the right thing.  And that’s what EMTALA is about.

 

Thanks,

Ed Leap

Doctors and Nurses ‘Getting in Trouble’ too easily…

Trouble

 

My column in the April edition of Emergency Medicine News

http://journals.lww.com/em-news/Fulltext/2016/04000/Life_in_Emergistan__Doctors_and_Nurses_Getting_in.6.aspx

Are you afraid you’ll ‘get in trouble?’ It’s a common theme in America today, isn’t it? We’re awash in politically charged rhetoric and politically correct speech codes. Our children go to colleges where there are ‘safe spaces,’ to protect their little ears from hurtful words and their lectures or articles contain ‘trigger warnings’ so that they won’t have to read about things that might upset their delicate constitutions. All around that madness are people who are afraid they’ll ‘get in trouble’ if they cross one of those lines. I mean, one accusation of intolerance, sexism, genderism, agism or racism, in industry, government or education, and it’s off to the review panel for an investigation and re-education!
Worse, I see it in hospitals now. I hear so many nurses say ‘I can’t do that, I’ll get in trouble.’ I remember the time I asked a secretary to help me send a photo of a fracture to an orthopedic surgeon (with the patient’s consent, mind you). ‘That’s a HIPAA violation and I’m not losing my job to do it!’ OK…
There have been times I’ve said, ‘please print the patient’s labs so they can take it to their doctor tomorrow.’ ‘No way! That’s against the rules! I’ll get in trouble!’ Seems rational. The patient asks for his own labs and takes them to his doctor. It can only be for nefarious purposes…like health!
Sometimes it’s even sillier. Me: ‘Patient in bed two needs an EKG!’ Nurse: ‘You have to put in the order first, or I’ll get in trouble.’ In fact, this theme emerges again and again when I ask for things like dressings, splints, labs or anything else on a busy shift. I’ve expressed my frustration about physician order entry before, and I know it’s a losing battle. But when there is one of me and three or four of them, and ten patients or more, it’s hard to enter every order contemporaneously. But I know, ‘you’ll get in trouble.’
I remember being told, by a well-meaning (and obviously threatened) nurse, ‘if I put on a dressing without an order it’s like practicing medicine without a license and I can lose my nursing license.’ Well that makes sense!
I overheard a nursing meeting not long ago, and it seemed that the nurse manager (obviously echoing her ‘higher-ups’) was more concerned with making sure the nurses didn’t do wrong things than with anything touching on the actual care of human beings.
I suppose it’s no surprise. ‘When all you have is a hammer,’ the saying goes, ‘all the world’s a nail.’ Now that we have given all of medicine to the control of persons trained in management, finance and corporatism, that’s the thing they have to offer. Rules, regulations and ultimately threats.
Of course, ‘getting in trouble’ applies to physicians as well. It just takes a different form. Didn’t get that door to needle, door to door, door to cath-lab, door to CT time? We’ll take your money. Didn’t get the patient admitted in the committee approved time-window? We’ll take your money.
Never mind that seeing patients in a timely manner is rendered nigh impossible by the overwhelming and growing volumes of patients, coupled with the non-stop documentation of said patients for billing purposes. Keep shooting for those times! Times are easier metrics to measure. Times are easily reported to insurers and the government. Times, charts, rules-followed, rules violated. The vital signs of corporate medicine in America today. (And don’t give me that ‘it would all be better with the government in charge.’ Two letters give that the lie: VA.)
No, we’re an industry constantly ‘in trouble.’ But not really for any good reason. We give good care as much as we are logistically able. We still save lives, comfort the wounded and dying, arrange the follow-up, care for the addicted and the depressed. We still do more with less with every passing year.
But odds are, we won’t stop ‘getting in trouble.’ Because for some people, waving the stick is the only management technique they know. Still, it saddens me. I’m sad for all of the powerless. The nurses and techs and clerks and all the rest who are treated as replaceable commodities by administrators who are themselves (in fact) also replaceable. I hate to see nurses, compassionate, brilliant, competent, walk on egg shells in endless fear, less of medical error than administrative sin. Their jobs are hard enough already without that tyranny, leveled by people who should appreciate rather than harass them.
And it saddens me for young physicians, who don’t remember when being a physician was a thing of power and influence in a hospital. They, endlessly threatened and unable to escape thanks to student loans, are indentured for life, short of a faked death certificate.
Finally, it saddens me for the sick and dying. Because we cannot do our best when our motives are driven by fear more than skill and compassion.
The truth is, however, threats only go so far. And once people have been threatened enough, there’s no telling how they’ll respond.
Just saying…

 

Show some patience in the bathroom debate

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I have to admit, I never thought that we’d be arguing about who to allow into which restroom. And yet, men and women who identify as other genders feel oppressed that everyone isn’t flinging open the stall doors to welcome them as bathroom-mates. And those (like me) who view it all with a little suspicion are considered worse than troglodytes for failing to keep up with modern progress and diversity.
Let me say from the outset that I am believe, absolutely, there are people who have issues with gender. There are those who are born with indeterminate genitalia, some with chromosomal issues or abnormalities of the endocrine system, and still others with psychological factors which make gender assignment or identity confusing.
However, that reality doesn’t obviate other concerns. Humans have been cautious about sexual predation for a very long time. In particular, but not exclusively, we’ve been suspicious about the motives of men towards vulnerable women and children. Maybe we have some deep ancestral fear of rape and abduction by invaders or raiders. (A thing well known to our forbears within about 200 years.) Isn’t it possible, therefore, that our heightened concern about this issue is not about hatred or intolerance, but represents a well honed biological instinct? That perhaps it is part of some evolutionary, survival-based instinct to protect those who are more susceptible to predation?
This may be why so many of us don’t like the idea of letting just anyone use just any restroom, changing room or locker room. These are often isolated places that typically have no back door for escape. It seems peculiar to me that while we are endlessly cautioned that college women have a one in five chance of being sexually assaulted while in university, we are mocked for having concern about opposite sex strangers in public restrooms. While it turns out the data on college rape isn’t nearly as bleak, the general concern about sexual assault is very real and reasonable.
Even if most transgender persons out there aren’t a particular threat, couldn’t it be that our concern over men lying about their gender identity, to gain access to vulnerable women or children, might be well-placed? And by the way, women are fully capable of sexual assault as well; a quick search for ‘teacher sexual assault’ will reveal a significant number of instances in which a female teacher sexually abused a student in her charge. Equality of opportunity also means equality of suspicion, you see.
Further, we keep hearing that transgender people aren’t pedophiles. Indeed, most probably aren’t. (I like to assume the best.) But neither are most men or women. And yet, most of us recognize the wisdom that a man alone shouldn’t chaperone a camping trip of adolescent girl-scouts, or be ‘house father’ to a sorority. And ask your female friends and family if they want male chaperones for their pap-smears, or if they prefer a female. And a lone young woman might not make the best choice to guide high school boys on a long field trip involving a hotel stay. These things make sense, if only to avoid the appearance of impropriety.
In addition, it is the height of politically correct folly to assume that because one has ‘transcended’ traditional sexual roles or genetic gender that they are, by default, above reproach and incapable of evil. In fact, it is demeaning to assert this. To be accepted as part of the greater collective of society is to be seen as human, not ‘super human.’ This means one is respected, seen as valuable, but also subject to the same laws and cautions as everyone else. Ultimately, since the fairly recent mainstreaming of transgenderism, I doubt if we have enough experience or data to make definitive statements about whether or not the transgendered have any increased or decreased risk of predatory behavior. I do think we can safely assume that those who would pose as transgendered are clearly dangerous, and for most of us I believe that’s the greater fear.
So why don’t we all show some respect for one another and some patience in the face of both titanic cultural shifts and time-honored mores. Then we might come to a reasonable common ground that respects differences and protects all the vulnerable.
Or to use more a more contemporary idea, maybe both sides of the issue deserve some tolerance.

I don’t think that’s too much to ask.

Do you?

Fighting drug abuse in the ER

Fighting Drug Abuse

My latest column in the Greenville News.

http://www.greenvilleonline.com/story/opinion/contributors/2016/04/09/commentary-fighting-drug-abuse-er/82713082/

I have a lot of ER stories that involve drug addiction and drug seeking behavior. I knew a patient who intentionally dislocated his shoulder three times in one day to receive pain medication. Another had a friend who stole an entire dirty needle box in order to rummage through it for injectable drugs.
I have been told by patients that pain pills were eaten by dogs, stolen by neighbors, lost in car crashes, accidentally flushed down toilets and all the rest. People have pled with me because their normal doctor was out of the country. One individual (call him Bob) came to me and was denied narcotics, then returned two hours later with a woman’s ID and saying he was she (call her Carol). ‘You aren’t Carol, I just saw you.’ ‘Yes I am, I’m Carol and I’m in pain.’ ‘Get out,’ says I. The list goes on and on and every physician has a few of his or her favorites.
In the annals of American medicine, it turns out this was all rather new territory, at least in scope. My career began in the early 90s when there were (for various reasons, corporate and otherwise) powerful initiatives encouraging us to treat pain with more narcotics pain medications like Lortab, Vicodin, Percocet and others. We were regularly scolded for being cruel and insensitive about people’s pain when we, young and innocent as we were, expressed discomfort with this practice. I remember being explicitly told, more than once, ‘you can’t create an addict in the ER.’
We were told that pain was the ‘fifth vital sign’ and were taught to use a ‘pain scale,’ which you’ll hear to this day whenever you interact with the healthcare system. ‘What’s your pain on a scale of zero to ten with zero being no pain and ten the worst pain of your life.’ Most nurses can say this in their sleep. We developed smiley face scales for small children to use.
We learned to give narcotics regularly for various types of pain, when they had been previously reserved for cancer, long bone fractures or significant surgeries. Medical boards were encouraged to discipline doctors who were reported to under-treat pain. And hospital administrators, ever in love with the ‘customer satisfaction’ model, pressured physicians whose patients complained about receiving inadequate pain treatment. (High patient satisfaction scores have been studied and associated with poor outcomes, by the way.)
Although it’s difficult to quantify because physicians feared for their jobs, I’ve spoken to many physicians over the course of my medical and writing career who were told by their employers to give narcotics when requested or risk loss of income or of employment.
This happened even in the face of staff who knew the abusers. We used to keep files so that even new physicians could tell who the problem patients were. Eventually, we were told to stop. It was a kind of profiling and it was unacceptable. Always assume they’re telling the truth, we were told.
Sew the wind, reap the whirlwind. Since 1999 prescription narcotic overdoses soared, quadrupling over the period to 2014 according to the CDC. Over that period there were 165,000 deaths from prescription opioids, most commonly Hydrocodone, Oxycodone and Methadone. In 2014, over 14,000 people died from those drugs.
Now, the move is from condemning our insensitivity to questioning our judgement. Prescription drug abuse is a high priority for state and federal law enforcement, state medical boards, the Drug Enforcement Agency and The Centers for Disease Control (which recently released new, more conservative guidelines for chronic pain treatment).
States are using online prescription monitoring programs and many hospitals are putting policies in place to give as few narcotics as possible in emergency departments. It’s a Catch-22 of course, as some patients with legitimate pain are told to find pain specialists or family doctors, when they either have no money to do so, or have no physicians in the area taking patients. Thus, they circle back to the ER where we try our best to remain both diligent and sympathetic.
Physicians and hospitals are now engaged in a constant battle to combat drug abuse, to save lives and help empower the families of those struggling with addiction, who are desperate to help their sons, daughters, husbands and wives.
I hope we maintain our compassion. But I also hope that it keeps getting harder to walk into an office or ER and get addictive, lethal prescriptions.
Because it’s time for this nightmare to stop.

 

 

My Most Important Patient

Medical stethoscope on keyboard as symbol for administration and office

Listening for heartbeat of most important patient

 

This was my column in the March edition of Emergency Medicine News, as linked below.

http://journals.lww.com/em-news/Fulltext/2016/03000/Life_in_Emergistan__The_Most_Important_Patient.13.aspx

My most important patient requires my constant diligence. For this reason, I am seldom far away from him. Only a few minutes inattention and there will be problems. I cannot forget my patient; I am trained to attend to him constantly. I am a professional, and my patient is, ultimately, my customer and the customer’s service is paramount, I am told. I am reminded by policies and procedures as well, and there are those who will contact me, day or night, regarding failure to do what my most important patient requires.
In these 29 years since I started medical school, I have seen many wounded and sick patients of varying degrees of complexity and interest. Legions of fevers and columns of colds, tribes of chest pains and nations of bruises, entire cities of coughs, herds (as it were) of nausea and vomiting and battalions of sprains. Flocks of fractures and entire civilizations of chest pain. But none of them, not one, occupied me like my most important patient.
I was guided by teachers in urgency and priority, I was taught to hurry here, take time there, but always be attentive. I was shepherded by wise physicians before me, but never did any of them put a patient on a pedestal the way my most important patient has been. Neither snakebite nor sepsis, aneurysm nor arterial blockage, pneumonia nor parasite has ever been thrust before me as the most important patient…until now.
What could he have, you ask? What affliction? Who could he be? Of what importance? Celebrity? King? Judge or politician? Child of my own? Parent or priest? Hardly. Not one, not even captains of industry who endow hospitals, have the power of this patient.
This patient, this most important patient of all, stares back at me all day long. I examine and treat him with my hands and sometimes my voice as I stare intently back into his face. I wander off to other ‘patients,’ but all pale in comparison to this one. He violates all privacy and priority and knows absolutely everything. I see a chest pain next-door, or a pelvic pain across the hall; a weeping suicidal woman a few rooms down. I come back and tell my most important patient each secret. The sordid or tragic details of every life I whisper to him, or write upon his screen.
Once my hands loved examining other ‘patients;’ the shape of normal and injured bone, the sound of clear and diseased lungs, the nuance of stroke, the tenderness of the abdomen that took so long to understand. Now I have no time. I must touch my patient, enter the password and let my well- trained fingers run across plastic, not skin or bone. Or speak into his ear with a microphone, far more expedient than time wasted with others. Far more important and billable.
Every time I wander away, my most important patient calls me back; ‘hurry, hurry, tell me about the others! Don’t take too long!’ And others humans, more important than I am, remind me. ‘Don’t neglect your most important patient! Finish everything he needs as soon as you can! He is the key to all of our money! And if you don’t, we will fine you, or punish you in some other way for failing to care for the most important one of all! But make sure the flesh ‘patients’ are happy; give them a little time or they might be upset and not come back, and then what will you tell your most important patient?’
My most important patient is now everyone’s most important patient. He (or perhaps sometime she) is in charge. Sometimes he is shy and recalcitrant and will not wake up, will not look at me with his glowing eye. When that happens, nothing can happen. No orders for labs, xrays or medicine. He is an angry god, and when he is angry no one else can be happy. Sometimes he is confused and plays pranks on me, so that what I thought I said to him is turned on its head or made unintelligible. He is capricious that way; but ultimately far better than ‘people,’ who say and do things that my most important patient isn’t programmed to understand or record. He doesn’t like that, and forces me to do things in a confusing manner because he is angry.
And he is a time miser; he wants all of my time and those who brought him to me (or rather brought me to him, a kind of sacrifice) know that he is greedy and yet expect everything to run as before, when other patients were important.
But I know, and you know, those days are gone like electrons on a wire. Because now, the most important patient of all takes the most time and the most effort and the most diligence because data and billing and tracking and policies are what he does and his handlers love those things the way we used to love humans. And spoiled as my most important patient is, I believe it is unlikely that anything will ever be the same again.
Pity. Humans are interesting. But sick or well, they simply cannot stand in the way of data entry.

FEEMRS: Fancy Expensive Electronic Medical Records System

I was at a locums assignment yesterday using FEEMRS. (You know, ‘Fancy Expensive Electronic Medical Records System?) It was all kinds of busy, with wait times of many hours. And as I slogged along, relearning FEEMRS after a few weeks away, I realized that it takes about one hour of looking at that screen for me to become exhausted.

It’s just too ‘busy.’ Every bit of the screen seems filled with some data, some field, some time-stamp. Oddly, I struggle to find the triage note, the home medications, the history. I struggle to find whatever orders I have entered and to see if they have been completed. I throw my hands up trying to discontinue orders and I nearly weep when it’s time to discharge a patient, a process which takes far too long with various orders, time stamps, discharge instructions, medicine reconciliations, printer selections and all the rest. Honestly, it’s far easier to admit someone to the ICU than to discharge them. At least in terms of computer time.

That’s the thing about FEEMRS. The ‘flow’ is all off. Oh, it’s data rich. But it’s mentally exhausting. Too many clicks, too little useful data, not nearly enough ‘white space.’

Furthermore, there are the orders to sign and the charts to sign. And after you’ve signed them, there’s another place to sign. And if the nurse so much as helps them to the door, and enters that fact with appropriate time-stamp, ‘0300, touched patient on elbow at door,’ well it’s going to need another physician signature to validate the elbow touching event and document that it was necessary, approved and billable.

Docs using FEEMRS across the country are daily beset by hundreds of orders that require signatures the next day; things we didn’t even know were orders. ‘Placed bandaid.’ ‘Paged nursing supervisor for admission.’

A friend of mine was asked to sign nursing orders for psychiatric meds (Psychiatric Meds!!!), placed by nurses for hold patients three days after he went off shift. He wisely refused but was told ‘its OK, everybody does it’

By contrast, this year and last, I worked at TMH (Tiny Memorial Hospital and its several campuses) where I (gasp!) used paper charts or dictated to a human transcriptionist. My patient’s meds were either in front of me or one flip of paper away. My discharge instructions were a check mark away, or three clicks on a different program. And often, for orders, I check a box and handed it to a secretary to enter into the system. In some instances, my prescriptions were written by hand (not perfect) and could be ‘deleted’ or ‘reconciled’ with a simple tear of the paper.

I notice, now, that when I go back to my hotel room after working with FEEMRS, I sleep poorly. No wonder. I’m clicking and looking, scanning screens and logging on and off until 2 am. I tell my kids to stop looking at screens before bed or they won’t sleep well. I keep it up till the wee hours.

FEEMRS is quietly, slowly, electronically killing all of us and making us less concerned with patients than we are with fields, files, clicks and saves.

Something has got to be done…

I just do n’t know what.

If this is an emergency, hang up and dial 911…

birdbig-withWordsButtonon-web.png

 

Currently, in American healthcare, experts are wringing their hands in confusion.  I mean, people have insurance, right?  And yet, healthcare is still expensive and dang it, people just keep going to the ER.  Visits are climbing everywhere and I can speak from personal experience when I say that we’re tasked with more and more complex and multi-varied duties in the emergency departments of the 21st century.

I’m not a medical economist.  I do have some thoughts on the well-intentioned but deeply flawed Affordable Care Act. However, I won’t go there right now.  What I do want to address is the ‘go directly to the ER’ mentality of modern American medicine.

Call your physician.  If it’s after hours, the recording for any physician or practice of any sort in America will have a message:  ‘If this is an emergency, hang up and dial 911.’  It’s a nice idea.  But of course, it presumes that everyone really understands the idea of emergency.  In fact, they don’t.  We understand that, or we try to, but we see lots of things that come in ambulances, or just come to the ER, that really aren’t.

‘I feel fine, but my blood pressure is up.’

‘I was bitten by a spider and I watch nature shows and I know how dangerous they are.’

‘I have a bad cold and I have taken two rounds of antibiotics.  I have an appointment with my doctor tomorrow but I thought I’d just come on in to get checked out.’

The list goes on.  In part, it’s because we do a poor job of educating people about their bodies and their illnesses.  Online searches usually result in someone self-diagnosing Ebola or cancer, so that doesn’t help much.

But in part, it’s because the ER, the ED, has become the default.  Surgical patients are told to have wound rechecks in the emergency department.  Kids with fevers are directed there by pediatricians or family doctors or secretaries.  People who need to be admitted are sent in ‘just to get checked before they go upstairs.’  Or sometimes, so the physician on duty can do the negotiation with the hospitalist, rather than having the primary care physician do so.

Why is the ED the default? In 1986 Reagan championed and Congress passed EMTALA, the Emergency Medical Treatment and Active Labor Act, which says you can’t turn anyone away for reasons of non-payment.  Another well intentioned bit of government meddling, it never provided any funds for it’s expansive act of compassion so many emergency departments and trauma centers simply shut their doors.  You can’t see patients for free all day and still meet your budget.  I think something needed to be done, but it probably went too far.

Fast forward.  Insurance is expensive even when the government mandates it. Whether for fear of litigation or due to over-booked schedules everyone else can always send patients to the ED day or night for any reason.  We still function under EMTALA and that will never, ever change.  Patients have little to no expectation of payment when covered by Medicaid and know it (and thus use the ED for everything, and I mean everything.  We are seeing expanding life-spans for the elderly, but with more complex illnesses being treated and ‘survived.’   We have fewer and fewer primary care providers.

Who actually thought emergency department visits would decrease, and why?  Did they ask anyone who saw patients on a daily basis? Or only lobbyists, administrators and progressive academics with starry-eyed fantasies?

I want to take care of everyone. But the Titanic that is emergency medicine in America is sinking.  We really, honestly can’t bear the burden for all of the chaos of our national healthcare.  And don’t tell me that if we have a single payer system it will change everything, because it won’t.  EMTALA will go on and doctors paid by the feds will not be more productive than they are now, so everything will still flow to the emergency departments and trauma centers of the land.

This isn’t about rejecting the poor, or even criticizing Obamacare.  It isn’t about single payer or Medicare for all. It’s about entrenched behaviors and facing the reality of the system we’ve created which allows one part of the system to attempt to carry the limitations of the rest.

Herb Stein, father of Ben Stein, famously said:  ‘If a thing can’t go on forever, it won’t go on forever.’

And if its’ true anywhere, it’s true in the emergency departments of this great land of ours.

Where the answer to every crisis is: ‘hang up and dial 911.’

The doctor will show compassion after he’s finished charting

I was working in a hospital recently and saw a note from a CEO on the computer. Notes and memos are ubiquitous these days. Bathroom walls, break-rooms, computer screens. Everywhere there is another reminder to check this, do that, mark those, record metrics, hurry up, don’t make mistakes, sign orders, complete charts, be nice and all the rest.

But this note stood out. In it, the administrator was reminding the medical staff that their job was tolerance, compassion and understanding. I’m not surprised by this. I’m aware that some administrators make ’rounds’ in patient areas and assess how things are going. (Concerns about HIPAA seem irrelevant, as I mentioned in a recent post.)

It seems, in a kind of ironic inversion, that the business side of medicine has tasked itself with telling the medical side how to be nicer doctors, better doctors, caring doctors. I’m not surprised; but I suspect it isn’t due to any collective epiphany about medical professionalism. Ultimately it’s really less about patient satisfaction, that Golden Egg that drives almost everything in medicine now.

But the irony runs deeper. While the CEO can hold forth on lofty, but important themes like understanding and tolerance, while various administrators can stroll through the ICU or various units shaking hands and making nice, physicians are doing something else. Lots of something else.

In the emergency departments where I work, physicians scurry out to see patients then run back to chart. And chart. And chart. And in many instances to sift through the endless possibilities of ICD-10 codes (I recently saw ‘2nd degree burn due to water skis catching on fire.’). Sometimes we are expected to code in more detail. Discharging a patient is, itself, often a complex process filled with orders, searches, clicks, signatures and locating the right printer.

I recently worked at a site with a shiny new nationally known EMR. ‘Please call the hospitalist,’ says I to the secretary. ‘Alright. Will you enter the consult order in the computer so I can document it?’ I’ve been handed faxes to fill out myself and of course, nothing gets done until it’s ‘put in’ the computer. Another rant for another day, as I digress.

The physicians rarely look up from their keyboards to chat, except when running off to see the patients who inconveniently stand between them and their real job of data entry, billing and coding. All done real time. If you don’t do it, by the way, you’ll get e-mails or texts the next day about your unsigned orders. ‘The coding department needs these right away.’

There was a time of collegiality. There was a time when we discussed cases and our feelings and our sorrow and our passion. That was when medicine was about people. Remember them? The upright primates on whom we practice medicine? Now? Now it’s about numbers and billing, metrics and tracking, satisfaction scores and rewards…and punishment.

Little wonder the CEO can round, or hold forth on the intangibles that lured many of us to love medicine in the first place. Physicians aren’t physicians anymore, not since we handed the reigns over to administrators so that we could ‘focus on the practice of medicine.’ And not since billing became so complex in order to justify every pen stroke, every bandaid, every pillow fluff. And not since the growth of administration, which has itself dramatically increased costs just as it has in universities across the country.

I want us to be tolerant and caring, compassionate and kind. But it’s hard to do when your entire job is less about humans and more about business. It’s hard to do when the volume of patients explodes thanks to unforeseen consequences of the ACA, the endless beatdown of EMTALA and the unending medicalization of everyday life. It’s nearly impossible when you’re tracked like a Caribou for every action and every key-stroke. It’s hard to do when there are no rests, no pauses, no coda in the great dance of emergency, or any other, type of care.

I often work in small, slower places. I do it in part because I can sit and talk. I can breath. I can think. Heck, I do it because I can act like a CEO.

Medicine is great. I love my work. But that’s the thing. I love my work. My real work. Meeting the sick and injured, figuring out what’s wrong, sifting through truths and untruths, danger and anxiety, solving problems.

I don’t love the slavery of modern medicine, which will be the same whether it is run by corporations or government. (So don’t kid yourself that nationalized care will solve this problem.) Governments and corporations are virtually interchangeable anyway.

Perhaps worst of all, I don’t like seeing my colleagues, young or old, as the joy escapes from them shift by shift, only to be replaced with exhaustion and bitterness. Or fear of some unknown repercussion from some faceless manager who leaves takes an hour lunch every day and leaves at five.

Maybe CEOs need to be lectured on how to have compassion and understanding towards their physicians and nurses. I think I’ll start rounding in their offices.

And writing my own memos…

HIPAA for thee but not for me…

Time for a rant!  I’ve written a lot lately about caring for our patients, and about caring for our spouses and those things make me very happy. But now and then, things rub me the wrong way.

I was recently working at TMH, or Tiny Memorial Hospital…my vague name for small facilities since I work at several and wish to preserve their anonymity.  While there a patient checked into the ED for a fairly unremarkable complaint, for which she was evaluated and treated in a reasonable time.

But before she left, we received a phone call from ‘the Mother Ship.’  TMH is part of a large system of hospitals.  The phone call was from the ‘foundation.’  Turns out our patient was a donor well known to said foundation.

Mind you, we never called them, texted them, e-mailed or faxed them. No consultants were contacted, no transfers arranged.  We were just doing our simple doctor and nurse thing.  But the Mother Ship was inquiring how she was.  Which means that someone was notified about her visit to the ED.

Now mind you, it may be that she agreed to this in the process of supporting the institution.  Maybe it was a perk.  I didn’t ask.

But what bothers me is that if any one of the nurses on staff had so much as looked up their own lab-work, they would have been terminated for a violation of HIPAA, the privacy statute.

http://www.hhs.gov/hipaa/for-professionals/privacy/

This is a common policy, but let me repeat it.  According to most hospitals’ interpretation of federal privacy statutes, looking up one’s own results on the hospital computer is a firing offense.  Not only so, but spyware is installed so that the staff’s home addresses are cross-linked to those of their neighbors just in case they look up someone else’s information…a friend who asks for information, for instance.

Furthermore, I cannot even hand a patient his or her lab-work to take to his or her physician the next day. Why?  It’s a violation of privacy.  I don’t understand, but I doubt if I’m supposed to understand.  (Almost all things federal dwell in a kind of fog impenetrable by logic and reason.)

But donate enough and someone will know when and where you went to the ER.   And that’s just good customer service, right?  Right.

Privacy, HIPAA, is for little people.

And yet: Quis custodiet ipsos custodes?

‘Who will guard the guards themselves,’ or as it is commonly rendered, ‘who watches the watchers?’

I don’t know, but I guess we all need to watch ourselves lest we end up fired.

The only other alternative, it seems, is to donate a lot of money.