Meaningful (Ab)use

January 1, 2012 brought another layer of documentation mandates to every office visit progress note. Meaningful use regulations added to chronic pain regulations in Washington have changed the context of many patient visits.  As of Jan 1 of this year I feel like I’ve crossed over the edge and now have to spend more time as a clerk than as a physician interacting with my patients.  I’ve succumbed to well-intended, government-imposed veiled threats and financial incentives, you could say fear mongering and bribery by our governments.  This has led me to agree to yet more documentation in every visit to show that in the case of pain management that I am complying with many abuse prevention practices, and in the case of Medicare my use of an electronic medical record shows meaningful use.  I guess this is  as opposed to meaningless use.

In the meaningful use arena the problem is in how the regulators define meaningful use.  At our office we have had an EMR since 1997, and take expend considerable effort to make very meaningful use of the information. We have a virtual disease management registry so that we can improve our efforts to assure our diabetic, hypertensive and hyperlipidemic patients stay on track to maintain good control of their health. We make attempts to get patients in for preventative care visits. We use printed prescriptions to reduce errors with hand written prescriptions.  Unfortunately in order to demonstrate the government definition of meaningful use, and qualify for a financial reward for meaningful use from Medicare, I need to do some other things with the EMR.  These involve taking time during patient visits to generate documents to pass out to patients at the end of the visit.  To a bureaucrat these may seem important, and maybe they are, but to me they mean I have to spend 2-3 minutes of each visit assuring that the patient’s gets a printed medication list and problem list, and then typing a visit summary and directions to give the patient.  This means that the note for the patient encounter has to be complete or nearly complete while they are in the exam room.  On a busy day I in the past have chosen to complete these at the end of the half-day so that later patients do not need to wait as long for me to get to their visit.  For some visits I agree that these are important. For other visits they are just extra work that either takes time away from direct patient – physician interaction or puts me behind in my schedule and late for the next appointment and every subsequent appointment that half day.

In the case of pain management I have done the mandatory 4 hours of additional education on the use of pain medications.  That was the easy part.  Now I need to document at each visit that I am abiding by the state regulations.  The concept of these is right on target, but the details of the regulations is onerous. Now for every office visit with patients on chronic opioid pain management we need to use specific tools to assess the individual patient for depression, opioid abuse risk, degree of pain control, level of functionality and be sure that every 6 months we have a new 20 point pain medication agreement explained, signed and documented in the chart.  After this if there is any time left we can actually assess the problem causing the pain and see if there is anything to do to help with that.

These new regulations are on top of the complicated set of rules for what we need to document in order to show to the insurance company that they should pay me and what I need to document to give our lawyers enough information to defend me if I am sued.  Oh, I also want to make a note that serves to help me or anyone else provide good continuity of care.

If I sound cynical it is not accidental. I feel like the newest regulations have gone over the top, and now every day I spend more time documenting care than I do providing care.  It’s silly, and I predict that these efforts will turn out to be counterproductive.  Patient satisfaction and actual quality of care will be lower as a direct result of government regulations designed to improve quality of care. There you have it, my experiences from my first 6 weeks of daily work under the 2012 Washington state chronic pain management regulations and the Medicare meaningful use incentive program.

As president Reagan famously said, “The most terrifying nine words in the English language are: ‘I’m from the government and I’m here to help .’ ”

5 Responses to Meaningful (Ab)use

  1. You’re Welcome Doc:

    What is happening to your profession means a lot to me, because it has already happened to mine. If we do not act to stop the governments involvement with our daily lives everything will be bogged down by them. I would think that people would be very interested in fighting your battle, so that the war is waged now and their jobs/income/careers and daily life are not next.

    When it was happening to us in aviation, specifically pilots, everyone said “they make too much money anyway”. Now you are the target. The government has a lot of power, and most often uses it in the best intentions. But you know what they say about the road to hell “paved by good intentions”. It would be a mistake to think the government is evil, they are not… but they are reacting to what we ask them to do for us. But its much better to do it ourselves. We should not rely on our government. I keep hearing echos of President Kennedy – “ask not what the country can do for you, ask what you can do for your country.”

    It doesn’t sound absurd to the lawmakers that you spend “just a couple of minutes extra” passing out a flyer. But thats what happens when the government, which is not an expert in anything at all, passes laws to fix problems. We don’t need laws to do the right thing, we just need participation by the people.

    A perfect example of this was after 9/11 the government put up a protective airspace around tall buildings, extending to 5 miles away. If you penetrate this by even a few hundred feet, when you land you will be arrested. The reason for this was to keep terrorists from hitting our skyscrapers. Now there aren’t any protective measures (missles or guns) installed, so these laws were erected to prevent the terrorists from flying too into buildings- after all, if you cant get closer than 5 miles, its impossible to crash into them right? WRONG!

    See, the only people that are hurt by this are non-terrorists. The terrorists don’t care about the new laws, but the pilot flying his family around downtown chicago, as he has for decades without incident will land safely and then get arrested for breaking this law and flying too close to the buildings. See, only the law abiding citizens will be effected – the terrorists will never answer those charges (they will be dead)

    Sames goes for the medications mentioned. The guys doing this stuff illegally do not care about the laws, people, they don’t care about anything. Period. The only victims we have from these new laws and regulations is that god doctors who TRIED to do the best they can will get in trouble. The illegal drug trade doesn’t care about pamphlets one bit. So this will not stop the trend.

    Yeah, Doc, most of us are with you! Im sorry if it doesn’t feel that way, but we are. And if there is a specific action in the future that you need done, like bombarding our reps with messages not to pass XYZ bill, let us know. The most successful also include a link to the reps names and numbers. We will be here when you need us.

  2. To LOU:

    For starters, have you noticed that their income has diminished in the past decade due to extreme malpractice insurance premiums? Their costs of operation are sky high. A doctor doesn’t make anywhere near what he used to. Do you think he should take a paycut again?

    Don’t forget the student loans of 250,000 dollars or more, staff, overhead, insurance companies setting his rates- if you really look at it, a doctor probably brings home a tiny percentage of the money his practice earned – any impact to his income abilities, even small ones, make a huge impact on his take home income (net)

    You better care about it, because if being a doctor isn’t lucrative why would they want this profession? And when you need the BEST doctor to help you- he won’t be there for you because the guy who could have saved your life decided to go into a profession where he could have made some really good money – with none of the headaches.

    These doctors don’t owe you a damn thing, yet they show you compassion and continue to make it work by sacrificing their cut. I don’t see you donating your time for free at your job. And here’s a question, what if he did take less patients and you were one he didn’t have time for. See, your care is in jeopardy too. Then your post would read: what’s the big deal, he only sits with you for a few minutes – he should speed it up, why do I have to wait 5 months to see him?

    Stop looking at other peoples paychecks – no matter what the profession – and demanding they take cuts and sacrifice. Because some day they will be after your job – and you will be sorry you didn’t fight for the doctors. The brain drain is a serious issue people, we don’t want our best and brightest going to wall street – and end up with Dr. Nick from the Simpsons!!!!!

  3. The last paragraph of your work description was upseting to me. Why does patient care need to go down because you now have to document a visit? Why not cut the number of patient visits in a day to allow for this documentation? After all an ‘Oath to save lives’ is still an Oath.

  4. Hey Doc, welcome to the club of professions the government turned into a pain in the ass. Congratulations! Let me give you the ten cent tour.

    As a profesional pilot we have been overly regulated for decades now. I know of no other profession that requires a three part test (written, oral, and practical exams) every six months in which you are putting your livelyhood on the line..Yup, if we fail the test we are history! And we aren’t just talking about useful skills assessment, but nuts and bolts in depth engineering.

    Don’t get me wrong, I think its a fantastic idea to have recurrent training, but do we really need to be asked questions about the fundamentals of aero, fluid, and thermal-dynamics? Do I need to know the the heating and air conditioning schematic? Do I need to know every parts name, function and tolerances – especially since I am also not allowed to fix it under any circumstances?

    We have pilots who have been in the USAF, flew fighters and bombers, flew in a given airline for 5 , 10, 20, even 30 years with no problems. And if they fail a “check-ride” it not only means you cant fly, but the next exam is by the FAA who has the right to REVOKE your certificates and ratings if the inspector decides to, with NO oversight, and NO checks and balances. What do I mean, I mean that I never get my day in court if that happens to me. This has happened to lots of great pilots, and their only recourse is to beg the NTSB (national transportation safety board) to mediate – IF they grant you a mediation, don’t count on it though.

    And flying a simulator, with someone evaluating your every word, with the power to destroy you is not the same as really flying a plane. The pressure and nerves get so bad for pilot, they often get sick before, during or after a check-ride.

    Like I said, if someone was not following regulations, they will bust him anyway, but to dangle your job, lively-hood, future in front of you when you have done nothing wrong, all because you lived another 6 months longer- its unfair. Its mean. And the people testing you are incentivized to fail you – because they are NOT ALLOWED to pass everyone – no matter how well they do. The amount and content we have no memorize for each test is the same as remembering everything you learned in college – without reference to a book, phone a friend, shout out, 50/50 etc etc. Its insane! But some lawmaker thought it was a GREAT idea! And it may sound great on paper – but there are thousands of victim pilots that did nothing wrong other than have a difference of opinion with the tester for example.

    I agree with the Doc, its wrong to regulate irresponsibly. I’m sorry they are starting to really put the spurs to you guys in recent years. I know because I live with it myself and it stinks!

Leave a reply