Cynical Thoughts about Medical Insurance

Is anyone else irritated by medical insurance companies' efforts to improve the health of their members by encouraging them to do recommended tests based on claims-made data? Recently, a patient asked me if he should get the pulmonary function tests his insurance company recommended based on his asthma diagnosis. He does have mild intermittent asthma. He uses a steroid inhaler once a year during the spring for about a month and might use his rescue inhaler with exercise four or five other times during the year. If you check the guidelines put out by the National Asthma Education and Prevention Program it is recommended that a spirometry test or PFTs be performed annually to assess any changes in lung function. The fact is, this patient has been treating his asthma the same way for about fifteen years. He feels fine. So will doing PFTs make a difference? We discussed it (over Christmas and through the patient portal, which I love) and decided that doing testing was unlikely to cause a change in therapy. Since he had better things to do than PFTs he would prefer to skip the tests. Hopefully he won't see an increase in his premium for refusing to follow his insurance company's medical advice. Does this make me worry about becoming nothing more than a flunky ordering tests for patients based on Humana or Aetna or Anthem's "best practices"? In a word, yes.

What irritates me more, is being faxed long lists of patient names with recommendations for mammograms, colonoscopies or diabetic eye exams. Our office is supposed to pull those charts and encourage patients to have their preventive exams. Of course if we do pull them, it turns out the "claims-made" data from the insurance company isn't all that accurate and many patients have already had their tests done. Thus another waste of the office employees' time pulling charts. Hopefully it will be easier with electronic records.

I suppose the cynic in me wonders "What's the angle here?". Does the the upper management of these companies really care about the members they insure that much? Is that what it takes to continue to make the obscene salaries their positions pay (see chart below)? When Humana sends me yet another envelope full of "healthy" coupons in their quarterly newsletter that shows me how much money they saved me with my last doctor visit, complete with lots of "healthy advice" enclosed, why does it make me roll my eyes?

When I want medical advice I will talk to my doctor or find an expert on-line, I will not talk to my insurance company. I do not want or need coupons from Humana. Nor do I want my insurance company to remind me of preventive care visits via my telephone. My patients are thrilled by it, however. "Humana pays for me to go to Silver Sneakers! Isn't that great?" or "A free 30-day Jenny Craig membership is available, what do you think doc?" 

Just call me Thomas, because I am a doubter. Nothing is truly free in the insurance business, so somewhere along the line the consumer is paying for the SilverSneaker membership and the salary of the individual who is soliciting companies to provide coupons from the insurance company. Please, just pay my claims and not give me such a headache trying to obtain my prescription from your 90 day pharmacy service. That's what I would call good service! 

http://www.ama-assn.org/amednews/2012/images/gbisf0531a.pdf

Physician Patient Communication

All professions need good communication skills. Obviously in healthcare the ability to communicate with patients should rank high in a physician's list of talents. These days that interaction occurs in a number of ways: face-to-face, direct telephone contact or though a staff member, via emails, patient portals, or even texting. Because the communication is in the arena of medicine, the protection of an individual's health information is paramount. Enter HIPAA, which is a federally mandated program to ensure patient confidentiality.

The face-to-face form of interaction is the most rewarding because multiple senses are used in the process. First, I listen to the words while hearing the tenor of a patient's voice; a few octaves higher with anger or fear, deep and gnarly from years of smoking, "push" of speech in an anxious or grandiose individual, or an accent that might be heavy enough for me to wonder if there is a cultural or comprehension problem. Sight gives me other cues; body language--crossed arms, angry face, tearful, an open posture, a resigned facial expression, stiff limbs or back. Sometimes my sight reveals more concrete things--bizarre tattoos, picked at sores, expensive accessories, worn and torn clothing. My nose may be assailed by the scent of the smoker, too much perfume, not enough soap, musty clothing or pleasant shampoo--all of that speaks to me. Finally touch--dry and peeling skin, a mass somewhere it shouldn't be whose texture may speak to me of reassurance or of terror. 

The opposite must be true as well. We speak volumes to our patients without opening our mouths, or despite opening them. The tenor of our voices may be patronizing, authoritative or uncertain. Our faces and body language reveal our thoughts with a roll of the eye, crossed arms, or open facies. We can look professional or casual. Smell can be important--what asthmatic wants to see a physician whose aftershave or perfume is overwhelming? Perhaps touch is the most expressive. Early on I learned that even when I don't need to, patients expect to have a "laying on of hands" in some fashion. They may trust you less if you haven't at least looked in an ear or listened to a heart. 

The hardest communication for me is remembering to finish with eye contact and a plan: "We'll contact you with the lab results", "I will have our referral clerk Megan call you" or just "Have a great holiday" instead of rushing out to see the next patient. But the best visits include a hand shake or on a good day, a hug. 

Be Careful What You Wish For

Physician-to-physician communication has become an increasingly difficult problem and its lack has worsened the fragmentation of healthcare today[1]. The challenge is complicated by many things:

• Physicians lack the time to call colleagues about patients when their income is patient volume-based 
• Fewer opportunities for direct physician contact, i.e. the doctor's lounge
• EHR systems cannot talk to each other
• Patients don't always tell their physicians about other doctors taking care of them
• Printed EHR records are so full of verbiage that important findings are missed by the doctors trying to scan pages of unimportant documentation
• Patients rarely carry their health histories with them in any format outside of memory

Another problem, at least in the healthcare system where I work, is the lack of a centralized area where physicians can come together to find community specific information. Blast emails are sent to doctors whose boxes are already full of "junk", making it difficult to separate the wheat from the chaff. Recognizing this problem I recently approached the IT department at my institution. 

It was gratifying to me that they not only understood the issue, but were excited about assisting in a solution. My vision is to create a Physician Community where providers can go to find answers and communicate in a secure environment about any number of issues--problems with EHR, announcements, medical directors' updates, calendars with CME and other dates of interest, blogs, CME, vlogs, links to outside trustworthy medical sites, and a place to crowdsource patient or system problems. IT gave me access to build such a community in a Sharepoint environment. 

Of course in addition to the problem of building the environment and populating it with what the doctors need, is getting them to use it. I feel certain that "If you build it they will come" does not apply in this situation. I envision needing to enlist lots of assistance from the President and CMO of the system down to the office managers and EHR superusers. 

I'm a firm believer that Social Media is the most important revolution in patient care today. Effective electronic communication between physician is part of that movement. But today, as I'm reading Sharepoint for Dummies, I can't help but wonder--what was I thinking and can this make a difference? 

References:

1. Shannon MD MPH, Shannon. peg.org. January/February 2012. http://www.perfectserve.com/resources/docs/ACPE-PhysicianCommunication.pdf

The Catch-22 of the Physician Champion Role

Yes, I'm a geek. When my girls were in high school, their friends were amazed that they received texts from their mother. One daughter has commented on Facebook that her mother is more tech-savvy than she is. At the beginning of 2012 my interest in the healthcare benefits of social media was born and I began blogging. I investigated and use LinkedIn, Twitter and Google+ while remaining attentive to Pinterest, AboutMe, Doximity, Instagram and others. So when my employer offered me the position of EHR Physician Champion for our physician group a couple of months ago, I took on the challenge. And challenge is the operative word.

Presently there are about 25 physicians in our 180+ multi-specialty group "live" (using electronic records). In a meeting specifically called to discuss "Provider Go-Lives", three individuals tasked with implementing EHR turned to me and said, "So Dr. Nieder, how can we encourage doctors who are not embracing EHR to do so." Hmmm....good question.

Let me preface these remarks by stating that our administrators have tried everything in their well-researched knowledge base to make this transition work. As we move forward improvements are made with every new Go Live. My immediate response was two-fold:

1. In training, don't give physicians the impression that using an EHR is using a paper chart in electronic form. It is an entirely new way to document and, unfortunately, the learning curve resembles third year medical school with IT support instead of attendings. It is every bit as daunting. 
2. Encourage the doctors to shadow with someone already successfully using the system. 

The next question was harder. "What can we do to push the physicians who are balking?" Ah, therein lies the rub. Of course I recognize that the question was also my responsibility in the role of Physician Champion. To answer it, I was going to have to do some thinking. There are many reasons doctors give for not wanting to use EHR as posts by Palmd, HealthcareTechReview, MITTechnologyReview, and others attest but the biggest one in my system is that it slows down physicians whose salaries are based on productivity. 

My understanding of the value of EHR is simple enough--more legible notes, better population care using "big data", enhanced patient care using clinical decision support tools, improved documentation to increase reimbursement, establishment of direct patient communication through portals, healthcare savings by reducing duplicate test ordering, and improved communication between providers in continuity of care. Even though our present system is poised to realize all these goals, the only one it is capable of performing at this very moment is legibility. So how can I convince physicians to use a tool that is going to slow them down (i.e. reduce their pay) and doesn't yet have the necessary functionality to improve patient care?

As a geek, the EHR experience has me torn between two emotions: incredulity at its lack of usability  and that sinking sensation I remember from the late 80's when the software rarely did what it was advertised to and crashed all too frequently, freezing the computer and forcing the user to restart both the software and often the entire system. The promise was there but the reality was long in coming. So too is today's EHR. 

An EHR Fantasy

Now that I've been using my EHR for more than three months, the muscle memory has taken over but there are still only so many clicks I am capable of doing in any given moment. Locating the right forms to insert, deciding how many templates to download, determining if I should plug the microphone back in between patients or carry it from room to room, figuring out the most expeditious way to document in the problem list from a scanned referral note or lab results and finding new ways to record a note, these things are all going to take a lot of time. Yesterday I came across an interesting article by Marla Durben Hirsch from the FierceIT blog: EHR vendors propagating a myth about their products. Amusingly enough, the article made me daydream:

I am in a room with a patient, iPad in hand. With touchscreen input, I easily target any templated buttons with my finger (instead of missing it with the stylus because it's not quite in the 'sweet' spot). There is a graphical interface that's pleasant to the eye, usable and intuitive. Dictation feeds directly into the chart from an adequately programmed microphone IN the iPad, so I don't have to cart a separate piece of equipment with a ten-foot wire. There are separate modules for each specialist and a broader one for me, the family doc. If I misspell a word, there is a spell-checker (incredibly, something my present EHR is without). To show an illustration to a patient I simply double-click the home button and choose the browser for the internet or another app to illustrate a point. If there's a video I'd like a patient to see it's up in an instant. From the iPad I can quickly email links, videos or relevant information to the patient. It rarely crashes, the screen can be enlarged or reduced depending on my needs. It is smaller than a laptop and less obtrusive than paper charts. I add apps specific to my interests or my patients. And they don't cost an arm and a leg. 

Alas I come back to the real world where my stylus still has to be placed just slightly to the left of the circle I'm aiming at. When I suggest to my IT support that hiring gaming developers might be a great way to improve the interface of our present EHR I'm really not kidding. Seriously, making patient documentation something inherently usable would go far to improve the acceptance of them with physicians. Despite claims to the contrary, physicians LIKE tech. We just expect the tech to be user-friendly. More specifically, we expect EHRs to work like the apps on our phones and our tablets. What a joy to look at a screen like this:

From the app iBP by Leading Edge Apps LLC

But no, my screen is riddled with tiny mono-color dots and clickorrhea is the name of the game. 

While patient care is serious there is no reason why electronic documenting could not be a joy to use. As more digital natives enter medicine they will be more insistent that the software they use to take care of patients be as easy to use as the apps they use to monitor their heart rates with exercise, check in with Foursquare, or text their friends. From my perspective, they can't get here fast enough!

The Thanksgiving Z-pack

Emma & Great Uncle Tim

Thanksgiving this year is likely to become one of my favorite holiday memories. My husband's niece, her husband, sister and fifteen-month-old daughter visited from Mississippi. We had a nice time showing them our pretty Louisville Zoo where Emma got a new hat to protect her ears. We ate a delicious turkey dinner, checked out some restaurants and explored Christmas lights in the "MegaCavern" which was an old crushed-stone mine now used for rentable storage and zip-lining.

Belle of Louisville in lights.

My daughters stayed up late with their cousins while Tim took to his job as great uncle with enthusiasm.

This year I was on call for our office which is usually quiet but a long weekend can be busier especially since we elected to keep the office closed on Friday. Typically the calls concern respiratory infections and urinary tract issues.

As I explained the normal symptomatology of an upper viral infection (or cold) to the patient on the phone Thanksgiving day, I noticed my husband's niece listening. When I got off the phone I said, "Everyone thinks a Z-pack is going to make them better. Typically the request for an antibiotic is about halfway through the process and in a few days, they feel better. They assume it's from the antibiotic but in reality, they were going to get better anyway." I could see the wheels turning in her head. "My doctor always gives me an antibiotic." So we talked about the negative aspects of getting an antibiotic every time she has a respiratory infection. The virus won't respond to it but the bacteria that live in and on her can become resistant to antibiotics. She will be at increased risk of developing MRSA--methicillin resistant staph infection, a skin infection that is difficult to treat. If she does develop a bacterial-caused illness such as a true bacterial sinus infection (usually one-sided sinus pain, purulent nasal drainage AND a fever), a skin infection, urinary tract infection or pneumonia, it may take stronger and more toxic antibiotics to kill the organisms. It is even possible that the infection could be fatal. A good over-view of this topic is here.

She was pleased that the pediatrician had not given her daughter antibiotics, even though Emma has been seen several times for various upper respiratory infections and stomach bugs. She commented that most of her friends' children were frequently treated with them. Obviously she can't control what the doctor prescribes for her but maybe next time she will ask, "Is the antibiotic really necessary?" Sometimes that is just the opportunity a provider needs to say "No, it probably isn't. Let's just try a little symptomatic relief and lots of fluid and rest!" Maybe another participatory patient was born this holiday.

A Humbling Experience

As Physicians are becoming aware, consumers of health care products (better known as patients in my world) are increasingly likely to leave reviews of their physicians on sites such as Healthgrades, RateMDs and Vitals. Of course the angry patient is more likely to vent criticism than the satisfied one unless the physician's practice is actively encouraging patients to go to the sites.

I use a service that emails me once a week with my data listings on several rating sites, including the ones included above. Rarely is there anything new but yesterday my email indicated a new evaluation. I clicked on the link and found the following comment, "Rolled her eyes at me with her head bent down when I told her I thought I had something going on--I presume she thought I couldn't see that gesture." Ouch! It is certainly not inconceivable that I did that. It is, however, very unprofessional. Was I burnt out that day? Was I actually rolling my eyes at the computer that tries my patience on an on-going basis? Had it been a horribly unproductive day and I wasn't listening the way I should have been? Whatever the reason the behavior was completely inappropriate. I believe in patient-centered care. No matter what was going on with me that day, my patient should not have felt undervalued and patronized. In checking the patient schedule from the day the review was written and the day before I could find nothing outstanding. Fortunately the review site allows physicians to comment (many don't) so I took the opportunity to apologize. More importantly, this gave me an opportunity to think about my reactions to patients and remember to pay more attention to my interactions, especially on days when I am frustrated or tired.

Physicians have long been protected from such reviews but as more and more "quality" data is released to the general public by the Centers for Medicare and Medicaid (CMS), not only will specific comments from patients be available but sites like Angie's List and Consumer Reports will use that data to rate physician practices.

It's a scary world to physicians, but frankly some days I need a little constructive criticism. The good news is when I get this critique: "Excellent physician. Will not tell you what you what to hear but tells you what you need to know. Does not claim to know it all and will refer to specialists (the best available) without a second thought. I trust her with my life and have for 19 years." 

Price Transparency in Medical Care

As healthcare costs become a bigger and bigger chuck of our Gross Domestic Product (GDP), price transparency is a subject that insurance companies and patients are talking about. The idea of knowing how much something costs, be it canned black beans in the grocery store or replacing the leaking faucet in your kitchen, seems obvious but it will be an uphill battle to enact change within the healthcare system. The concept seems simple--make prices accessible to the people who are paying them just like in any other service industry. While healthcare is more complex than a plumbing job, there are still some things that should be easy to price--cataract extraction, blood pressure check, yearly physical, uncomplicated appendectomy. The hidden prices and unknowns in medicine can quickly add up. It is no wonder that  patients are angry, frustrated and incredulous.

Case in point, my mother called yesterday to ask why she was not told that going to a cardiologist in our system for a test was "outpatient treatment" in a hospital. She had no idea that was the case until the  EOB (Explanation of Benefits) came from her insurance company with a charge specifically associated with that. The answer is that the cardiologists are employees of the hospital so there is an additional fee tacked on to her bill. Even though her visit appeared to be in a doctor's office, it is now an extension of the hospital. As such they tack on a "facility fee" that, while technically allowable, I find distasteful and misleading, even as it is done by my own healthcare system. Talk about a lack of transparency! My mother had no clue and at 84, even if someone did explain it to her, I doubt she understood what they were talking about. Not until she got the EOB from her insurance company did she start to question.

A patient with congenital heart disease told me this week she was putting off getting an imaging study on her heart because she can't afford the $1000 hospital fee that her now-hospital-employed physician would be adding to her bill. One thousand EXTRA billed dollars solely for that reason??? How do hospitals justify this? They state that patients are paying for the "added services" that being a hospital-associated facility affords them, like infection control and patient safety. I doubt anyone thinks paying four times what the doctor charges for a facility fee is justified by patient safety. For another take on this please read: Medical Billing: a world of hurt.

It's encouraging to see patients becoming more involved in this process--pushing for price transparency[1]. Doctors are also beginning to understand that we can no longer hold ourselves above the fray, believing that caring for the patient in the best manner possible without knowing the economic burden that care incurs to the patient or family is not our concern. Best care does include knowing costs. In the meantime, my patient who needs the echocardiogram waits, and hopes for the best.

1. Outofpocket.com. Lori, Mona. Frisbie, Patrick. 11/07/12. Flying Aces Incorporated Inc. 11/10/12 http://outofpocket.com/Blog/2012/11/07/TheBiggestQuestionNoOneIsAskingInHealthCare.aspx

Patient Access to Their Data

The Open Notes initiative has created a flurry of interest in the on-line medical community but not even a blip that I can tell in my personal world. Patients appear oblivious. The story was not covered by our local newspaper. No physicians are nervously or otherwise discussing it in our doctor's lounge.

Despite Meaningful Use criteria breathing down our organizations's neck, which includes patient portals with the capability to obtain their records electronically, no one is talking about this important study: three healthcare systems, Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in  Pennsylvania, and Harborview Medical Center in Seattle participated. This included 105 doctors and more than 13,000 patients. When the study was finished 99% of patients surveyed wanted continued access to their notes and NO DOCTORS opted out. 

The last phrase is the most important one to me as a physician. In my world doctors are often very nervous at the thought of patients obtaining access to their own records even though technically the patient owns the record. Yet the more I see of charting, especially electronic charting, the more important it is that patients have the ability to access and help us improve their records. 

As an example, I recently had a new patient who related being involved in a motor vehicle accident many years ago. He'd had surgery shortly after but he wasn't sure whether or not he'd had his spleen removed, though he knew it had ruptured. This is important because individuals who have no spleen are at increased risk of certain kinds of infections and need routine and regular followup vaccinations to protect them. The first thing I did was access records from an abdominal hernia surgery he'd had just a few years ago, to repair a hernia he had as a result of the first surgery. The operating doctor dictated in his note that the patient had had a splenectomy. I wasn't convinced so I dug a little further and fortunately the hospital still had records of the first surgery (by law the hospital does not have to keep records from over twenty years ago). The patient did not have his spleen removed and thus needs neither recurrent vaccinations or  expensive imaging to figure out the answer. But what if I'd just taken the mistaken word of the second surgeon? How much better if the patient had been given easy access to his records years ago when he'd first wondered? 

Soon, patients will have access to their own charts and will be capable of giving much better histories or better yet, will have their medical stories in their own Personal Health Records. This can save a lot in time and unnecessary tests, not to mention improved accuracy in patient records. Because after all, who has more at stake in the accuracy of the record than the patient? Or as e-Patient Dave deBronkart says: 

Communicating via Patient Portal

It's Saturday night and I'm tying up loose ends, signing off patient referral letters, sending messages to staff to do on Monday and "playing" in the test environment of our EHR to try to better understand it. My husband is working a 12-hour shift at an immediate care clinic, my daughter is with a friend and the cats are not trying to get in my lap right at this moment. The house is quiet, with nothing but the soft swishing noise the dishwasher makes and for some reason, that always soothes me. Maybe because cleaning is happening without my active participation. It occurs to me that I haven't checked RelayHealth.com, our patient portal, since early yesterday morning. 

RelayHealth.com

I log on and there are two messages. One from a patient that needs her atorvastatin refilled. I thought it had been done at the time of our visit yesterday but when she arrived at the pharmacy only her blood pressure pills were there. Apparently I neglected to check the drop down box in the prescription area of our EHR. In her case the default setting was "record" instead of "send to retail pharmacy" (it varies per patient for some mysterious reason) and I missed checking ONE of the three prescriptions correctly. This is a system problem that needs to be addressed but in the meantime my patients will sometimes get less than all of the multiple prescriptions they need refilled. The good news is that she figured out how to use the portal, sent me a message, I read it and immediately logged back into the EHR system and sent the prescription to the pharmacy. Then I messaged her back to say the prescription should be ready in the morning. COOL!

The second message is from a patient who has found data regarding the use of metformen and psychiatric disease. She is tech savvy and figured out how to scan and send me a PDF file of the published research. COOL! Now I'm learning from my patients even when I'm not in the office. I send her a message promising to read the article and get back to her and jokingly tell her that I hope all my patients aren't as smart as she is or I'll be inundated with reading material. Tomorrow I can respond to the article.

So far not a large number of my patients know about or have bothered to sign up for the portal but I've been very happy with the interactions I've had on it. Earlier in the year a woman had an illness that seemed to linger forever. I was running tests and talking to specialists and was certain that this would pass but it was frustrating for her. I think it helped both of us that she could communicate directly with me throughout the illness and may have saved her some trips to the ER or Immediate Care Center because she had direct contact with me on a nearly daily basis. In return it was a relief to me to know how she was doing.

Physicians often hesitate to give this kind of access to patients because they are afraid it will be abused but that is short-sighted. Just like with the telephone, I have complete control over whether I answer or my medical assistant does. This way it can be done at my convenience and, in general, I hate communicating by telephone. Most patient messages are quick and to the point. If they need to be seen, I tell them so. It's a plus to patient care from my perspective and am pleased with the results. I hope my patients feel the same way. 

The Three "P"s of Mayo--Patient-centered, Physician-led and Collaborative Partnership

Last week I attended the Mayo Clinic's Annual Social Media Summit in Rochester. What most impressed me had nothing to do with the conference. On Tuesday afternoon before the Summit began I toured Mayo Clinic. It was supposed to be for an hour but lasted more than two because our group, consisting of one doctor and nineteen PR professionals, was so interested in the information being fed to us. I don't know why the publicity folks were so intrigued, but for me Mayo's philosophy of "patient-centered, physician-led" care hearkened back to a time when the patient-physician relationship was inviolate. It was stimulating to realize that my instincts of how medicine is best-practiced are right on target.

My myopic opinion regarding the fragmentation of healthcare sees the destruction of the patient-physician relationship by multiple entities, who are primarily interested in a piece of the economic pie, as central to our healthcare mess. At Mayo, no project moves forward unless there is a physician who champions it and it is the physician's responsibility to ensure that every project is dedicated to improving some aspect of patient care. Physicians are salaried so they spend the time necessary to care for patients and are not incentivized to increase the numbers of patients seen or do procedures to enhance the bottom line. 

Every person I met who worked for Mayo reiterated the importance of putting patient care and comfort first. It was incredibly refreshing. The Mayo logo emphasizes a patient-first policy as well. I'd seen the logo multiple times but somehow never thought about what the three shields represent. Our tour guide explained: Patient care, research and education. The educational aspect was obvious as we walked multiple floors of patient care areas. I noticed no TVs in patient waiting rooms but many had computer screens where patients could learn about their conditions. It is a refreshing and calming atmosphere without the cacophony of media noise. There is art everywhere. Waiting rooms are spacious and well-lit. Meditation rooms and educational spaces abound. 

Children's waiting area

Mayo has always represented excellent healthcare in my mind. Patient reports that come to me after a visit there are extraordinary due to the extent of the integrative care the patient experiences from multiple medical disciplines coming together. I expected to be impressed. I did not realize I would also be reassured. Putting patients first is what I'll continue to strive to do, despite insurance interference, governmental policies or EHR dysfunction.

Flu Shot Day

It's the time of year when my MA chases me around the office until I acquiesce and let her give me the flu shot. There is no rationale for this. I don't even mind shots but for some reason I put it off as long as I think it is safe. I feel the same way about clothes shopping, which is why I mostly do it on line. But no one ever died because they didn't go shopping for jeans.

So for anyone who has a reason for not getting the flu shot please watch the following. If you've already had yours, you might want to watch this anyway cause it's slightly funnier than placebo (and a little off-color):

And for those people who "never get sick" and therefore don't get the flu shot, please see this by Zubin Damania.

Thanks. (OK, now where did my MA go...)

Post-its and the Practice of Medicine

Ever since the first Post-its® appeared in the early 80's I've used the little colored sheets to remind myself about all kinds of things--telephone numbers, todo lists, shopping lists, dates to remember, notes for other people-especially my husband. I do not know how my mother, with her organizational genius, managed to survive without them.

When I began using a superb productivity program called Omnifocus, I thought my Sticky Note® penchant would be reduced. However, with the advent of EHR, I find it has done anything but. They clutter my desktop (my REAL desktop, not the one on my Mac) with quickly scribbled suggestions for changes requested or features not found on Allscripts (our EHR), thoughts for the blog, thoughts for future Vlogs, need for specific patient information, a book or website suggestion from a patient or my grocery list as I dream up an idea for supper tonight.

Later in the day I will quickly go through the stickies and move them to my calendar, Omnifocus, or if possible I'll "just do it" (using a time-management technique by GTD® guru David Allen). They are ubiquitous in my exam rooms for writing quick info down with patients--a web site, recommended reading, an address, or medical term most often. Almost as frequently, they remind me to do something for a patient that would take too long to enter into the Electronic Health Record (EHR) or more commonly, it's unclear where to put it in the EHR--like getting old records out of storage, obtaining recent ER notes, or looking up some particular disease state to research for the patient.

It's clear that most other forms of paper will be disappearing from my office. Already the huge stacks of charts are disappearing, replaced with tasks or scanned documents in the EHR. Slowly, I'm beginning to appreciate the uncluttered appearance of my desk. However, I've found that its glass top, something I never used to see, makes a great surface for sticky note adhesive. 

Guest Blog: A Patient's EHR Point-of-View

Barry Comer, blogging at Thoughts/Rhythms, gives a poet's impression of the EHR experience:

In June of 1966, several crew members begin dying from a mysterious depletion of salt, extracted from their bodies. The crew’s doctor anaylizes post-mortum and discovers by instrument, the phenomenon’s cause. 

Of course this is the fiction in 1966, envisioned by Gene Roddenberry for the 23rd century. The imaginary “tricorder” in the doctor’s hands is for wishful dreamers and possibly envied by my physician, in 2012. 

With the introduction of electronic medical records (EMR) to the patient/physician dialog, neither the future nor a “diagnostician in a hand” have arrived. Clumsy to learn, intrusive in use, EMRs in form and function are short-reaching obstacles, that chart their course with manual input and uncertain results. 

Some tools in the 21st century disappoint and others appear with malice. Because EMRs are still untamed and newly minted, their usefulness arrives as a mixed blessing. 

They say, “time heals all”, but our relationship is in trial to stay in the moment.

My physician is intuitive, intelligent and listens carefully. She possesses a black belt

in medical counsel, that appears clairvoyant. Her holistic relationship to my body and mind is why I call her my doctor. The EMR pushes that trust backwards. It conspires to break her gaze from me and worse, has taken certainty of our relationship, into the “getting to  know you” process again.

Not only do I depend on her words, I put trust in her eyes. But when they stray, I feel the magic leave by the tiny keystrokes and space bar taps, filling the exam room. Our agreed upon relationship is breaking and hear it in her sigh.

This was not the future promised and feel once again, that some technologies are better left in clinical trial, with release contingent on both aesthetic and functionality. Without both, advancement seems muted by imagined giggling of software authors in the bushes. 

Not all things advanced by the goalkeepers make for better analysis and savings. Growing suspicious has been supplanted with hopeful resignation. It may get better and after all, 

I may just have a cold.    

Nostalgia and the Local Pharmacy

Recently a patient in our practice requested his Plavix renewal from a 90-day mail order pharmacy. When the "estimated" price came to $585 he decided to stop taking his cardiac medication. In exploring his insurance website I found that the actual cost would only be $200. In addition the company had a "Do Not Substitute" order on the prescription (something his cardiologist denies writing) and the cost of the generic is $28.59. Wow--the drug he almost quit taking because of the website price estimation was, in reality, 96% cheaper than originally thought. 

Contrast this with a phone call I received recently from Wish's Drugs, a local pharmacy here in Louisville. The pharmacist paged me on a Saturday morning regarding a patient's medication. I called the pharmacy and the pharmacist answered the phone(!). He suggested that my patient get a similar drug for half the cost of what I prescribed and asked if that would be OK. When I hung up the phone it struck me how pleasant that had been. Not just that the pharmacist was looking out for the interest of our mutual patient, but the call from start to finish--a real person answered the phone and it was the person I needed to speak to. Not only did I not push three different buttons and listen to three different voice messages along with a sales pitch for flu shots, but I immediately spoke to a person knowledgable and caring about my patient and her medical condition. Contrast THAT with the 90 day site where the patient, unknowing, was supposed to go back to his insurance web site, check the price of his medication and THEN go back to the pharmacy web site and decide that he could actually afford the medication because the real price to him would (only) be $200. No friendly pharmacist in that other state willing to make a phone call and get his patient a better deal on his medicine. 

It's not that I think mail order pharmacies are inherently evil, it's just that the service component is reduced to the patient. However, interestingly enough, the two studies I read regarding mail-order vs. local pharmacies [1,2] found patients are more compliant when they use mail order. Perhaps this is because when medicines are delivered right to the patient's door it reduces extra steps, making it easier for patients to remember and obtain their drugs?

In my experience patients enjoy the convenience and economy of getting 90 days worth of medication delivered to their mailbox but when there is a problem they are quickly frustrated by the difficulty of explaining to someone in another state what their needs are. As a physician, I am annoyed with the same difficulties, plus the frequent faxes asking about changing patients to a "cost-savings" alternative, something the patient is usually unaware of so we have to call him/her, ask their permission, explain what the change entails, etc. Just one more thing in my over-extended day that I don't have time for. 

Mail order pharmacies are not going away and local pharmacies where the pharmacist knows the patient and cares for him/her in a more intimate way are disappearing into distant, nostalgic memories. Given the studies quoted here, maybe that's a good thing. Does my desire for it to be different, for every patient to have the individual attention of the good pharmacist at Wish's make me out-dated?  



1. Schmittdiel JA. The comparative effectiveness of mail order pharmacy use vs. local pharmacy use on LDL-C control in new statin users.J Gen Intern Med. 2011 Dec;26(12):1396-402. Epub 2011 Jul 20
2. Duru OK. Mail-order pharmacy use and adherence to diabetes-related medications. Am J Manag Care. 2010 Jan;16(1):33-40

Continuous Partial Attention

Continuous Partial Attention--while reading a blog post this morning that term jumped out at me. The last few weeks of juggling a laptop while talking with patients have made it obvious how easily distraction can take away from the doctor-patient interaction. Right now the computer interferes with my ability to give complete attention to my patients' stories. Did I have the same problem way back in third year medical school when my first ? I don't recall taking pen and paper in patient rooms back then, but do remember trying to juggle all the things I needed to ask--chief complaint, history of the present illness, past medical history, family history, medications. Then there were things that needed to be looked at--vital signs, physical exam, nurses notes, ER notes--followed by the assessment and plan. These were all foreign terms and workflows to me. Was I intensely listening to the patient then or more likely, worrying about what I'd forgotten to ask, or do, or write down or study? My earliest instance of Continuous Partial Attention (let's call it CPA so I don't have to keep writing that term) with patient care must have begun then.

Early in practice I found ways to control the CPA triggers--a snack of nuts or fruit around 10 am to keep my sugar from dropping out; keeping the phone on silent (there are medical programs on it that I use routinely so I can't leave it on my desk); using meditation techniques to bring me back to the patient if I find my brain wondering off; exercising and sleeping routinely so I have enough energy for my day.

It's not just doctors who have the CPA issue. Many times I recognize the same thing going on with the patient--the gentleman this morning who needed to be at work and was only half-listening to my advice regarding his medication and exercise compliance, the woman who thought bringing three kids to her physical was a good idea, the patient who was recently diagnosed with cancer and nearly oblivious to any other health concerns, or the husband with a terminally-ill wife paying little attention to his own health (or me).

Surely the CPA will fade away as I find a path to making the electronic record become as unobtrusive as the paper one once was (hint to IT dept--smaller tablets would help with this...just sayin'). In the meantime, one of the more important lessons on the EHR learning curve is finding a way to move the laptop out of the center of the conversation--figuratively and literally.  

Friday Morning Overload

Somewhere mid-morning on Friday I lost control. Things were perking along very nicely and then suddenly (or so it seemed to me), I was nearly an hour behind. Up until then even my EHR notes were signed at the end of each visit. Perhaps it is my German heritage, but my skin begins to crawl when patients wait more than fifteen minutes. For years it has been a matter of pride that they rarely waited longer than five or ten minutes and frequently they were seen within a minute or two of their appointment time. Nor did patients feel they were getting short shrift from me. My scheduling clerk knew her business and the patients well enough to pad an appointment when necessary. In the last three months that has not been the case. Hopefully this is temporary due to the extra time involved in learning our new documenting system but being behind brought me to a reflection on the importance of timely appointments.

Sometimes, no matter how good my intentions, the cards are stacked against me--Mrs. Jones lost her job and her mother in the same month; Mr. Bausier came in for a cold but just happened to mention the pressure sensation in his chest that seems to be more frequent and is associated with exertion; and in listening to Mrs. Roberts' heart it is obvious that the rhythm is just not right. And all in the same morning. Other times, it's more personal--I'm talking to a patient whose daughter went to high school with mine and we have to catch up or my favorite French national comes in who prefers to tell me her medical problems in her native tongue. Not because it's better for her but she knows I need the practice. 

On Friday, my schedule was so off that by the twelfth of thirteen patients that morning my sugar was low, my mood was cranky, and my thought processes had slowed to a crawl. Frustratingly, somewhere in the brain fog I recognized those last two patients did not get my best care. Did they recognize my distress or just think that Dr. Nieder didn't care about their needs? Statistically patients have a problem speaking up for themselves in a doctor's office[1,2] and in my own uncomfortable state of mind it is unlikely I would have picked up on their discomfort!

Someday, hopefully soon, the office will find the right balance in scheduling for our new system. For now, I'm taking a lot of deep breaths and hoping that patients know I still respect their time and am struggling to give them good care under difficult circumstances. 

1. http://healthecommunications.wordpress.com/2010/09/01/five-reasons-why-people-do-not-ask-their-doctor-questions/

2.http://newsroom.pamf.org/2012/05/patients-fear-being-labeled-difficult/

Mission Accomplished

Mrs. Smith is adamant, "That amlodipine is making me tired! I can't take it." Ms. Smith is 86 years old and her blood pressure is reaching a systolic of 200. She's still mentally alert and volunteers at a local hospital every week, drives herself to places nearby and lives alone. It is scaring me because I don't want her to stroke. This is the third BP med she has rejected in as many months. I've checked for other causes but think her age is just catching up to her.  Previously she has had a systolic in the 150's and several years ago we tried several meds, all of which she refused to take. I gave up then but now I'm much more concerned. She has no family to speak of...we go over the pros and cons of the medication. She reluctantly agrees that if she dies from a stroke that would be fine but being in a nursing home unable to talk or walk would be horrible. She will try the medication for another month. "But doctor if I can't do the things I want to do, I am not going to keep taking it!" She agrees to try it and surprises me with a hug as she walks out the door. "It's OK Dr. Nieder, I'm not going to live forever."

Tim Jones slammed his finger in a door and sees the hand doctor on Monday for a non-displaced fracture of his little finger. He wants to ride this weekend in a 100 mile bike ride for some charity or other. "Honestly, what is the risk?" We discuss the fact that the ride itself could cause swelling of the fingers and lots of pain, not to mention if he falls and hits it. "They splinted it really well at the immediate care center. I promise not to take too much ibuprofen." I give my blessing and hope he is safe.

Mary White arrives, late as usual. My staff is used to that, so they try to schedule her at the end of the day. She has a short litany of minor issues, brings me up to speed on her minor medical problems with specialists, has her yearly exam, we discuss her perfect blood chemistries and she is out the door. 

After 25 years, my patients have me well-trained. And vice-versa--they only call me at night with true emergencies and they apologize when they wake me, they rarely call for last minute refills because they forgot, they bring their meds with them when they come for an appointment and they arrive on time because I'm on time (well, at least I was until Electronic Health Records began three weeks ago). Reflecting on my practice it occurs to me that this is what I hoped my patient relationships would be like at this point in my professional life. 

Mission accomplished. Wonder what comes next?

Burning Out on Friday Afternoon

Recently a Mayo Clinic sponsored study reported that the rate of physician burnout was much higher than other careers in the US[1], especially among front-line specialties like Family Medicine. This Friday afternoon in preparation to seeing my last patient it hit me "Is this sensation burnout?" Inwardly groaning--a new middle-aged woman with obesity and several psychiatric meds, my thoughts ran to "Who put her on my schedule damn it. It's Friday afternoon. What did they think they were doing? Doesn't anyone care about MY needs when they're scheduling" or words to that effect. For a few moments I pondered my office life.

Lately, my office looks cleaner, because EHR (electronic health records) hides the mass of unfinished charts instead of having them all stacked on my desk. Now there is no obvious sign of all the work I do--no notice to my employer that I am an important, busy and valuable doctor. Despite the reduction in mess, I rarely leave the office before 7, often am there until 9 and everyone keeps telling me that it will get better, since we're only four weeks "in". This is exhausting me but at least my husband frequently meets me at the door with a glass of wine in hand. For this I am grateful since sometimes I finish up my charts on-line from  the couch.

Then there's House Bill 1, the irritating and unfriendly-to-patient-care narcotic bill that takes up extra time and deprives my patients of therapeutic medications and remains a thorn in my side.

Add to those aggravations the everyday frustrations of practicing medicine in today's fragmented healthcare system and maybe I needed to worry. This line of thought hit me as  I took a big breath, walking in the door expecting the worst and spent the next thirty minutes with a delightful woman who was already taking steps to improve her health. She was working with a trainer, she'd already started losing about twenty pounds. She was upbeat and interesting and I walked out of that room energized.

This Friday I got lucky. Maybe next Friday I'll be drained. Reflecting on the end of my day I realized that's just how the rhythm flows in Family Medicine. Like most professions, some days are better than others, but looking at the averages, my curve is mostly on the up. I still like what I do.

1. Shanafelt, Tait D. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. August 20, 2012. http://www.webcitation.org/6AtdqOc4p

An EHR Obsession

My Saturday morning walking partner asked me yesterday, "So when do you get to quit being an IT professional and go back to being a doctor?" Wow, good question.

In the not quite three weeks of this new form of documentation I have been consumed with trying to understand and make the EHR work for me. No longer do I have to consult a "superuser" every ten minutes with questions but every day I'm trying to figure out the most efficient way to care for people using this frustrating new tool. The "muscle memory" is beginning to kick in thank goodness, so time per patient is less. Now my frustrations are more with what seems to be a very inefficient system. I struggle to determine whether I am the problem or the EHR is. Most likely it's a little of both. The term Mission Hostile User Experience coined by Scot Silverstein comes to mind. What is scary here is the potential for patient harm - between my distractibility due to the steep learning curve of the Allscripts system, the fact that no one has told us how to clean these "Toughbook" fomites that we carry from one patient exam room to the next, and the patient care error potential inherent in the software itself, these are the ever present worries that keeps me up at night.

On Thursday of this week, the EHR Steering Committee for my organization will meet and I will have the opportunity to present the go-live experience and make suggestions for improvement as other offices in the system go live. Throughout this process there has remained a sense of re-inventing the wheel, which seems odd considering that Allscripts EHR has been in existence for years, having gone public in 1999.

At any rate this blog is obsessed with EHR right now--but the essential question remains. When do I get to go back to taking care of patients?

Patient response to Electronic Records

Amazingly my patients have had a very patient response to the introduction of EHR (Electronic Health Records) to our office. They sit and watch me type and curse with an air of amusement and calm. More calm than I am feeling.

Yesterday began our third week of EHR. Muscle memory has kicked in and I saw 15 patients without running too far behind. Seeing 20ish patients daily again is starting to look feasible. Someone walking into my office no longer has to look over mounds of paperwork to see me. My only concern is whether my employers will cease to understand how much work I do if they can no longer see the physical evidence of it.

On an up note, there will soon be a couch in the area where the credenza is now. Since my colleagues warn me that it will continue to take longer to finish my charts it seems reasonable to have a comfortable place to do so. The main purpose of the credenza was to support the hundreds of charts I needed access to on a daily basis. The staff is very supportive of the change as well (wonder why...).

Many patients have followed me over the 25 years I've been in practice. While little has been different in the exam room until now, there have been lots of other changes--two previous locations, private practice to employed doctor, hospitalists, urgent care centers, and oppressive insurance controls to name a few. For the first time in two weeks, I was able to gauge patient reactions to this new-fangled way of documenting. Prior to yesterday I was too bogged down with clicking boxes, losing screens, figuring out where to put a new symptom the patient just threw at me, finding templates and vital signs and generally being absorbed by the Allscripts system to observe my patients (and please don't make me worry about what I may have missed in patient care over the last two weeks while I followed this steep learning curve).

Now I carry this new contraption in the room:

My younger patients hardly notice it. They would not have commented had I not explained its newness and why it was taking a little longer to enter information than usual. Older folks regarded it with expressions ranging from dismay to perplexity. Most of them commented before I did.

• "Do you like it?" 
• "Do you think it will ultimately speed you up or slow you down?" 
• "How hard is it?"
• "Did Baptist (my employer) force you to do that?"
• "What happens when the system goes down?" (I wonder about this one myself)

No one seemed particularly surprised or overly worried about my use of a computer to document their visit. They all seemed impressed when I stood up and said that their prescriptions were already at the pharmacy. 

At the end of the day what most impressed and humbled me was the sense that within their acceptance of this new device was a trust that regardless of the way I document their care, it would still be delivered in a way helpful to them.

At the end of the day, that's what it's all about, isn't it?

Finding a Better Way Down the Electronic Pathway

Clicking on a link from Twitter this morning, I read an article about how distracting email is in the workplace. That got me to thinking so I googled "digital distractions" and found this amusing infographic by David McCandless: 

http://www.informationisbeautiful.net/visualizations/the-hierarchy-of-digital-distractions/

It's hard to see on my blog but my favorite part of the visualization are the words "partner shuts the lid of laptop on your fingers" encircling the star at the top. Sometimes I want to do the same to myself. One of the more physically painful manifestations of "too much computer" happened last week when my eyes began to sting, burn and water after going live with electronic medical records. Adding six more hours a day looking at the screen was some sort of ocular last straw.

In the risk vs. benefit analysis of computer use, where is the balance? Wednesday night I participated in an #mHealth twitter chat on the topic of "access to medical literature". This was primarily about researching tools and how to find articles but because of the chat, it occurred to me just how often I utilize Twitter to access current medical information. Most of my contacts on Twitter are involved in mobile health or patient care so lots of very relevant information is tweeted and I click on the links. From genomes to medical policy to the latest treatments for atrial fibrillation, it all comes across the feed and when I have a moment I click, read or save and go on with life.

It's still unclear to me how to balance my time, choose wisely with my clicks and still fill my life with all the other important moments. If someone else has found a better way down the electronic pathway, please let me know.

An Electronic Health Record misAdventure

We thought we were ready. We had all our training. The staff was pumped. The doctors were apprehensive but willing. Tuesday morning "GO LIVE" began. Fortunately the hardware folks just happened to be in the office installing our dual monitors, so there were two techs present when none of our medical assistants (MAs) could access their tablets. Uh oh...

Shortly into the day our office manager discovered that the stand-alone electronic prescribing software we'd been using for years had been turned off since Friday and prescriptions sent electronically since then had never made it to their destinations. Patients were calling. They weren't happy. And we had no way of knowing who they were because our workflow is to fill the prescriptions, document in the chart and file. Uh oh...

Meanwhile, my MA was still unable to use her laptop to triage my first patient. I was waiting...Dr. K had seen a patient, documented most of her note but she could not put in the plan for some reason. This was a problem that went on all day until it was determined that her 'profile' was corrupted. IT promised a fix by the next day. Uh oh...

Remember being told to "save, save, save"? Dr. I, not big on computers to start with, was humming along only to find out that one of her electronic notes, on a complicated patient, had vanished into the ether due to a Citrix glitch, never to be found again. She was nearly in tears. Uh oh...

Finally, my MA had a patient ready for me to see. Only an hour behind. It was a young man, a new patient in for what the scheduling staff was told was an uncomplicated physical. I remember being told that this patient was perfect for the first day on EHR "He's young and healthy, a great start to using the Health Maintenance Template". Except that he was drinking a pint of bourbon daily with a blood pressure through the roof, a urination issue, chest pain and was anxiously depressed. Uh oh...

It is very difficult to have one's attention divided by electronics when it needs to be concentrating on a real person's medical issues. If I had to grade myself with how well that first patient was treated by me, it would be close to failing. It felt like a return to medical school--working blind, feeling incompetent, trying to speak two different languages at once (electronic and paper) and never quite sure anything was being done well.

Rumor has it our skills will improve over the next year. My hope, as one of the first primary care offices to go live in our organization, the technical support staff and the doctors can help other offices begin this journey with a refined send off.

This is a hospital "go live" but still hilariously hit close to home:

Dangerous 18 Hours Shifts in Nursing Homes

A nurse friend of my husband's was recently let go from a Kentucky nursing home for medication mistakes made while working two back-to-back, weekend, eighteen-hour shifts. I didn't believe that was possible under labor laws but I can find no maximum labor law covering how long people can be asked to work.

I'd be curious to know if this is a common practice in other places. I found this document, put out by the  Department of Health and Human services, that described nursing homes using 16 hours shifts as non-traditional, flexible hours for employees. By the time you add in breaks and lunch, I assume this is the same scheduling my husband's friend was talking about working. There is no suggestion in this document that these hours might be dangerous to patient health. There are well documented studies illustrating the increasing errors that occur when nurses work more than 12 hour shifts[1].

Even if an individual conscientiously gets enough sleep prior to one 16-18 hour shift, there is not sufficient time to sleep enough when shifts are back-to-back on a weekend. The nurse described here found her abilities slipping, particularly as she entered the end of the second shift.

This kind of care is unconscionable and has no place in the care of our elderly population.

1. Roger,Ann. The Effects of Fatigue and Sleepiness on Nurse Performance and Patient Safety. 2008, Apr.
http://www.ncbi.nlm.nih.gov/books/NBK2645/

22 Days into Implementing KY's "Emergency" Narcotic Regulations

(This is the second of my blog series on KY's "Pill Mill Bill". Please access the first blog post here)
At some point in the discussion of the perfect storm created by Kentucky's new narcotic-prescribing bill someone asked "How can regulations that aren't going to be enforced until October be considered emergent?" I have no clue what the answer to that is but I can give an update into my office's attempt at implementing the regs. Let me start by describing it as chaotic, confusing, time-consuming, and utterly frustrating.

We have patients calling from other doctors' offices who want to switch their care because those physicians have thrown their hands up in frustration and are simply refusing to prescribe any controlled substances. We are not accepting any new patients on controlled substances until the dust settles. I spoke with an ER doctor a couple of days ago who told me it is taking 15 more minutes per patient who needs a controlled substance prescription. I was unable to find any statistics on how many patients leave an ER needing a narcotic or other scheduled medication, but given that it is an acute care environment, one could assume at least 25%. Emergency Departments are already over-crowded, so imagine the issue with increasing the waiting time due to these ill-conceived, burdensome regulations added to a law already over-reaching in its original form, now with many more medications than originally intended.

I try to explain the regulations to patients, including the need to have urine drug testing because of their Ambien (a sleep aid of mild abuse potential) or testosterone prescriptions. Their expressions and questions are of disbelief and frustration.

• Question: Will my insurance pay for the drug tests?  Answer: I have no clue. 
• Question: Why am I being treated like a drug abuser? Answer: Call your governor. 
• Question: Am I going to have to be seen every three months? Answer: As long as I have to run a KASPER report on you every three months--yes.
• Question: Will my insurance pay for those visits? Answer: I have no clue.
• Question: Who thought this up? Answer: I'm not sure but I'd recommend asking Governor Beshear that one too.
• Question: I've heard some doctors are just not prescribing controlled substances. Are you going to do that too? Answer: No, uh, let me qualify that. I don't think so.

Despite Governor Beshear's reassuring words "For doctors who worry their ability to prescribe will be compromised, you have nothing to fear", it is taking my associates and me an average of twenty minutes per patient to explain the regulations, have patients sign informed consent papers, obtain drug tests, and run KASPERS. We only have fifteen minutes slots for patients so this is, of course, making us run behind all day long. And we are about average in the number of patients we have who take a controlled substance. The bill in its original form, covering only Schedule II meds (drugs like Oxycontin, morphine, amphetamines) and Schedule IIIs with hydrocodone would only have been an inconvenience during flu season with cough meds. But with the medications added in the emergency regulations, it's a nightmare).

So far I have run maybe fifty KASPER reports. How many have had any surprises on them? ZERO. Let me repeat that number--ZERO. Not one of my patients have had any controlled substances that they have obtained in this state over the last year that I didn't know about. Let me repeat that number--not one. When I asked the ER doctor what he thought of the law, he said, "This is a waste of time. None of the KASPERs we are running have anything of significance on them. The people that come in here who are drug-seekers we know about and we don't get KASPER reports on them because we don't give them controlled substances. Everyone else have clean reports. And the people from out-of-town we can't get a report on anyway." Then he said, "Oh here's your patient's KASPER. It has one entry." I guessed, "The 20 Valiums I gave her last February?" His response? "Yep. That's it. A real abuser, this one." She's 75 years old and her family begged me to prescribe something to help when she is completely overwrought with caring for her demented, terminally-ill husband. So far she's taken two of them. Yep, a real abuser there!