Wand Waving Part 2: Common Sense is Uncommon

Let’s jump right  into the second part of PookieMD’s dissertation on the Medical Home.   As you recall, I was reviewing the 10 rules of the medical home, as set forth by the National Committee for Quality Assurance.  The next three concepts are NOT new, and are, you guessed it, common sense.  (Why is common sense so uncommon?)

4.  Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information and to clinical knowledge.
5.  Evidence-based decision making. Patients should receive care based on the best available scientific knowledge.
6.  Safety as a system property. Patients should be safe from injury caused by the care system.

Let’s tack number 4 next: “Shared knowledge and free flow of information…”  I think this is a thinly veiled reference to an EMR.  I am completely for nationwide use of an EMR, but am dismayed at the piecemeal, haphazard free for all that has ensued.  The EMR needs to be accessible to health care professionals across all spectrums of care.  Therefore, the myriad of programs out there are not going to create a system of good access for providers and patients.  It has been proposed that there be a nation wide EMR for all health care providers to use.  I am hesitant in advocating this, as many tout the VA’s system as the model.  I am loathe to advocate anything the VA uses, as I would summarize my experience with all things VA using two words: “profoundly inefficient.”  However, a nation wide, user friendly EMR  would probably be the best option.  BUT,  it has been estimated that it will cost $36,000 per physician to implement an EMR.  Where’s the money coming from?  I don’t see a huge surplus (!) coming any time soon into our Nation’s budget.

5. “Evidence-based decision making.”  No argument here.  I believe this is the very foundation of modern medicine in the West. 

6.  “Safety as a system property.”  It scares me that this is a rule.  Didn’t we take an oath to “do no harm?”  It also scares me that the folks at my favorite institution, the CMS (Center for Medicare and Medicaid Services), have bungled their way in to making rules to keep the patients safe from bed sores, c diff and catheter infections through the “Never/Ever No Pay” rules.  (See post below.) 

So what’s so new and exciting about the Medical Home?  No much so far, just more costs to the physician, a slick new name and a lot of press.  I’ll tackle the next ‘rules’ the next post.

For more info on EMRs, visit Dr. Kevin Pho’s informative post at http://blogs.usatoday.com/oped/2008/10/why-doctors-sti.html.  For more on the technical aspects, see Dr. Josh Schwimmer at http://www.healthline.com/blogs/medical_devices/2008/10/problem-with-emrs-in-united-states.html

Cheers!  Don’t let your hands cramp writing those SOAP notes!

The Medicare No Pay, Never Ever List

The Centers for Medicare and Medicaid Services announced 10 hospital acquired conditions for which it will not reimburse.  The no pay rule has been in effect since October 1.  So, with out further ado: (drum roll):

  • “Stage III, IV pressure ulcers
  • Fall or trauma resulting in serious injury
  • Vascular catheter-associated infection
  • Catheter-associated urinary tract infection
  • Foreign object retained after surgery
  • Certain surgical site infections
  • Air embolism
  • Blood incompatibility
  • Certain manifestations of poor blood sugar control
  • Certain deep vein thromboses or pulmonary embolisms.”  (List from AMedNews.com Aug 25, 2008).
  • CMS began to implement the no pay rule October 1, 2008.  Physicians will still be reimbursed for their services, but hospitals will not be reimbursed for their portion of the care.   Now, I don’t know about you, but I agree  some of the events are absolutely “never-ever” events  (retained surgical object, blood incompatibility), but some of the other conditions are out right ridiculous.

    My colleagues and I have come up with some ideas on how to respond to this latest demonstration of government “efficiency.”  We have proposed “buttocks rounds”, where the wound RN examines every patient’s behind and charts presence/absence of pressure ulcers.  We thought it especially important to do this on those 35 year old youngsters we are obligated to admit for chest pain.  We also thought that perhaps we could have a “fanny cam” to take pictures, so our documentation would be impeccable.  We advocated noting that all patients had decubs at admission, but the hospital administration shot this one down.

    Our next suggestion was that every patient, no matter what, should have an admission urine analysis, to document presence/absence of infection.  There could be a little check-in kiosk where the patient signs in, hands in a credit card for the hefty co-pay, and pees in a cup.  The patients could even dip their own urine, and record it on their check in information to speed the process up and decrease labor costs.  Additionally, we thought surveillance ua’s would be helpful in all patients with urinary catheters, probably daily.  Got to nip that e. coli in the bud!  We also considered putting a mandatory quinolone on every order set for patients with catheters, but became concerned when we realized c. diff may soon be added to the no pay list.  It may be worth a try for now, though!  Too bad about the cost of all those extra ua’s.

    As to falls, I have little to offer on prevention of the noscomial hip fracture.  Our hospital uses bed alarms (frequently it requres a doctor’s order, though), and of course we can always get a sitter.  (However, all the hospitals where I work discourage sitters secondary to cost.)  Occasionally we try to get family members to stay with the sun downing patient,  but they rarely do.  Now that Granny is in someone else’s care, they will give some sage advice, like “Don’t use ativan, or haldol, or ambien or seroquel, because Granny gets really nuts with those.  And don’t restrain her either.  Bye.”  They then hurry to the car for their first meal out in months.  Who could blame them? 

    CMS is planning on expanding the no pay list to ambulatory settings, nursing homes and home health agencies in 2009. 

    I am always in favor of intelligent uses of government regulation, but someone missed the boat.  What do you say we make some fanny cam rounds at CMS?