Herds

Haven't written about medicine in a while.  My quality scores got tabulated.  I looked at everyone's feet if they have diabetes and everyone's blood pressure got taken.  My Too High Hemoglobin A1c measure exceeded goals which doesn't surprise me since people are sent because their diabetes has been poorly controlled despite previous physicians' attempts to control it.  What they could not tell me is whether those numbers reflect my treatment or the treatment of the prior prescriber whose handiwork I inherited.   It makes a difference since my annual bonus is tied in some way to the effectiveness of my work though I may be economically victimized by my own willingness to take on some of the most intractable diabetic circumstances around and have high HbA1c scores assigned to my care before I've made my first medical decision.  The Management could not tell me how this assessment of lab results is assembled.  I did very poorly on smoking cessation measures.  Not because I encourage people to smoke or neglect the reminder that they quit.  There is a box that indicates whether you discussed it?  Absolutely checked YES.  Was it completed?  Of course not, they are still smoking?  However the right answer is also YES because the intent of the question was whether the discussion was completed.  So my scores on that are low, not having figured this out until a few months before Son of NextGen became our Electronic Record that I still do not know how to navigate on this four months after implementation.  And finally there is the requirement that a plan be created for every obese patient on every visit.  Nearly all my diabetics are obese.  They are not sent to lose weight but to reduce their glucoses so they are not both obese and hyperglycemic at the same time.  Insulin makes them heavier.  I have no means of changing how insulin works in storing nutrients.  And if there were effective measures of slimming people down short of having a surgeon reduce the efficiency of their innards, we would have been doing that decades ago.

Yet in the tradition of a Milgram Experiment, Obamacare has a provision for requiring the medically ineffective, and sometimes even the inane, and people in authority follow suit with little question on how this jives with the realities of medicine and even nature.  Now, somebody is willing to pay the hospital and ultimately me a premium for doing stuff like this so if they tell me how and it does not deter effective and justified medical care I'm perfectly willing to shake a few extra shekels from the Medicare Trust Fund too.

Computer Upgrades

Our hospital patient care system was sold to the management with a hint that they would collect their money faster and in greater quantity.  In the minds of clinicians, the core business of the medical center is patient care with revenue as the byproduct but too little attention was given to the clinical capacity of our Electronic Medical Record which has been a struggle to maintain.  My clinical notes are now pages of cut & paste and carry over from last time.  The designers had the saichel not to put spell check or grammar corrections into the doctor's note writing.  I and many others have learned to leave the grammatical errors in the text as the only way a recipient reader can wade through a multipage report and find which few sentences came from the doctor.

Next week rolls out an updated version.  It would be hard to create a downgraded version of NextGen.  In preparation all users had to take an on-line course and a three hour lecture course to figure out how to use it.  I didn't really figure out how to use it as much as I learned what it could do.  If you were to ask me to add a series of fifteen 3-digit numbers I could do it accurately in a couple of minutes, not so much because I attended a few blackboard sessions in fourth grade but because there was a certain amount of drill and experience that accrued as a user.  My many complaints about prescription writing, scheduling tests, creating lists of often used medicines, replacing inane pharmacy defaults with defaults of what I might actually ask somebody to take, all of these were always there but nobody really showed me how to use them the best way or checked with me in two years to see how it was going.  So while I am in California later this month without the patients coming at me, I will try to set a time aside to customize this in a way that makes it more useful.  The notes will not get more professional as a result but with a little luck I will be able to look at the patients more and the screen less while we occupy the exam rooms.

Electronic Medical Record

My first day in Mercy's outpatient Endocrine Office, saved by no-shows which enabled me to struggle with their electronic medical record, a system called Nextgen.  Our financial institutions and travel systems have taken full advantage of computerization, though our medical systems have been laggards.  While I think there is much to be gained, the systems that I have encountered do not seem to be able to template a complex present illness such as diabetes particularly well.  One worthy project might be to compare dictated History of Present Illnesses with those templated.