In the last post we saw how complicated the visit is from Dr. Ron\’s perspective, and how many things were working to pull him away from our hero, Chuck. So what about Chuck? What about his perspective? I ended the previous post with the statement: \”All Chuck knows is that his back hurts and that perhaps buying the Roomba wasn’t such a good idea. He just wants to make sure there’s nothing serious going on, and he wants to feel better.\”
In other words, Chuck is interested in two main things:
What he wants to avoid is:
Please note that I could have used \”dysesthesia\” to keep with the \”D\’s,\” but chose to speak English (a talent which many doctors lack).
Now, when Dr. Ron listens to the story of a patient like Chuck, there are three main tasks he focuses on:
- Ruling out serious problems (or assessing risk).
- Treating symptoms.
- Making a diagnosis.
He does this by listening to Chuck\’s story (his symptoms), looking for objective findings (via physical exam, labs, or other tests), and looking over Chuck\’s back-story (his past problems, symptoms, and risk factors).
From Chuck\’s vantage point, as long as Ron has ruled out bad stuff and makes his back feel better, he doesn\’t benefit from making a firm diagnosis. That\’s what Chuck thinks he\’s paying for (both from his wallet and from the precious moments of his life wasted in the waiting room). But here\’s where things start to get complicated: Ron doesn\’t actually get paid for the two things that Chuck wants the most (ruling out bad stuff and treating symptoms), instead he\’s paid for:
- Coming up with \”diagnosis\” (problem) codes to describe Chuck\’s situation.
- Coming up with \”procedure\” codes to describe what he did in the office.
- Doing his medical record in a way that \”justifies\” his codes to insurers (in case he\’s audited).
- Paying a bunch of staff to make sure this information is submitted exactly right, as any mistakes could result in denial of payment.
Ron\’s new fancy-schmancy computer record program is built to make sure all of the information needed to justify the charge is put in properly, and that the diagnosis codes and procedure codes are also properly entered so they can be electronically submitted to the insurance company. Ron likes the fact that it makes this easier, but it bothers him that so much of the note is just \”packaging material\” that obscures the most important part of the note to both doctor and patient: the plan.
To make matters worse, Ron has to find a code from the ICD-9 code list, which are specific codes that the insurers accept for treatment. This is sometimes hard, as the codes for common things (like weakness of the arms) are mysteriously missing, while codes for strange things (like being injured by a space ship) are on the list.
To \”improve\” this situation, the government is soon to introduce ICD-10, which will increase the number of codes by 500%, now including the important code for \”burns incurred from flaming water skis\” (it\’s about time).
Ron\’s EMR gets to these codes (relatively) easily because they are essential to be paid.
Additionally (and worrisome to Ron), the insurers are taking these diagnosis codes and problems on the list to measure the \”quality\” of Ron\’s care. Ron worries about this because payment is increasingly being linked to quality measures, and the folks doing the measuring are the ones doing the paying, which means they would benefit from measuring low. Another negative of having problems accumulating on lists is the all-inclusive nature of the lists, which include:
- Chronic disease (like diabetes, hypertension)
- Past events (heart attacks, cancer)
- Symptoms (back pain, fatigue)
- Risk factors (family history of heart disease, cancer)
- Abnormal test results (high cholesterol, low sodium, abnormal chest x-ray)
- Exam findings (heart murmurs, skin lesions)
- Minor problems (allergies, baldness)
- Acute problems (Viral infections, sinus infections)
This makes these lists grow quite large, which is often made worse if the acute problems are don\’t drop off of the list, which is often the case. Taking the time to clean up and organize records is something most doctor\’s offices don\’t have time to do.
What does this have to do with Chuck\’s Roomba-assisted back injury? Nothing good. Unfortunately, it makes Ron focus on the least important thing: the diagnosis (remember, Chuck really just wants to rule out bad things and feel better). It rewards doctors for finding problems and doing procedures to fix those problems. It also rewards Ron for putting things into the chart that makes it jumbled and confusing. Since Ron\’s pay is dependent on his documentation, he spends much of his time and energy putting information into the record, as Chuck sits and watches him type.
So, for the 10 minutes in the exam room together, the majority of time is spent inputting information and finding diagnosis codes. Ron feels bad about this, a feeling that tempts him to do what many doctors do: order x-rays, MRI scans, and prescribe medications for a simple back strain. But Ron knows that these do nothing useful for Chuck and just raise the cost. Ironically, Ron\’s decision to do the right thing makes Chuck wonder about how good of a doctor Ron is, as he leaves with nothing to show for his time and inconvenience other than a sympathetic look, instruction to take ibuprofen, and a back exercise sheet. It seems like a waste of time and money.
Ron agrees with this assessment, wishing that he was rewarded for doing the right thing, not penalized. Both Ron and Chuck leave the visit frustrated. Chuck goes home to plot against his cat, while Ron moves on to the next patient, hoping for something a little more satisfying.
To be continued….
5 thoughts on “Adventures in Medicine: Part 4”
Interesting and humorous take on documentation. If you had me working for you I would be able to take your dictated comprehensive assessment of the encounter and accurately assign all the codes. Can’t help but wonder why you’re doing this yourself…doctors are not coders and should not be. ICD-9 and ICD-10 codes are nothing more than a universal language that allows reporting of diagnoses. The problem comes in when “notes” contain little to no information and that impacts the ability of the “translator” (your coder or biller) to do their job. Patient records should be complete so that no matter who reads the record they can identify what’s going on. You could have saved yourself a lot of grief by engaging someone trained in the business of translating clinical language to coding language.
The point is not that it’s hard to put things like codes into records (although the simple fact that I would have to pay for an FTE to do the task raises some red flags), but that most of the information in a medical record is not there to provide clinical care, but instead to support the billing. I know this is true because I no longer need to document for billing purposes. I am able to document simply for patient care, and the difference is stark. This is one of the reasons cost of care is so high: we have turned documentation into a vehicle for billing, not a means to better patient care.
Yeah, I know all of what you just said in your reply, too, which is why I often feel like I totally ended up on the wrong side of that record. As interesting as documentation can be on occasion, after a while it all starts to look the same because no matter what problem(s) the patient has, the objective of documentation is to get paid. And that goes utterly and completely opposite of what I always said when I thought I still had the potential to become some sort of physician: that it was never about the money, which I saw as a “nice side effect”. (I mean, I would have still wanted to be able to pay off the resulting debts and have a decent life, but the point was always the patient because of where I came from.) And, from the patient side, I am fortunate to have a couple of “old timers” for primary care, so they don’t usually give a rat’s behind about the documentation at the time of the visit and the computer doesn’t end up feeling like the elephant in the room getting in the way of communication between patient and provider. My other doc (who’s probably only about 10 years or so younger than my PCP, so also been around a while) doesn’t have EMR, so there are NO computers inside the exam room, and that I really like. But the coder in me is still really curious what kind of documentation he’s got, just because I see it all day and I know different providers do it differently if they weren’t trained on the EMR.
Gotta say, LOVE the Artwork. 🙂
Speaking of “How It’s Broken”, here’s a list of The 100 Most Influential People In Healthcare: http://www.modernhealthcare.com/article/20130824/INFO/130829987/100-most-influential-people-in-healthcare-2013-text-list
Out of 100, only about 30 are MDs. Of these, maybe about 3 see actual patients (check out the # of Ins Co executives).
My vote goes to Dr. Rob. Keep up the Good work, we need YOU on this list.
A doctor named Rob bucked the system,insurers he wanted to diss them,
and lo and behold,
a movement took hold,
his patients they all want to kiss him.