Same Doctor Visit, Double The Cost

On August 26, 2012, the Wall Street Journal published a story describing a situation whereby a patient who sees a physician employed by a hospital essentially pays double out-of-pocket what they would have paid for the same exact office visit with a physician NOT employed by the hospital.

I actually wrote about this situation in January 21, 2012.

Beyond what the Wall Street Journal reported, what's going on?

Assuming all things equal whereby a private practice physician and a hospital-based physician are equally competent and the supporting staff for each are both equally good (such assumptions are debatable in some circles, but will be ignored here), it all comes down to money.

When a patient sees a private practice physician, the government-established fee schedule only incorporates payments to the physician.

When a patient sees a hospital-based physician, the fee schedule not only incorporates physician payments, but also additional payments to the hospital.

Now, the patient doesn't pay what insurance covers in either scenario, but typically there is a copay or coinsurance payment that the patient is responsible for that typically is 20% of the total charges.

Here's an example using the Medicare fee schedule from 2002. I elected to provide "old" 2002 data as this information can be found easily and corroborated, but rest assured, the numbers are starkly different and perhaps more lopsided today. Medicare was selected as it is the bar to which all other insurance plans are typically based on.

In a physician run private practice, the only charges that are incurred is from the "Physician Fee Schedule". In a hospital-based practice, a patient incurs not only the physician fee schedule, but also additional charges based on the "Outpatient Prospective Payment System".

As you can see, the physician fees are slightly higher in the private practice setting compared to hospital-based practice... BUT, given the additional hospital charges involved with a hospital-based practice, the patient ends up being charged more per service for a simple clinic visit ($16.48) than if they had been seen in the private practice office ($10.06).

The cost differential for the patient is far worse with any procedures ($62.62 versus $342.47).

For the same exact procedure or service, a patient automatically ends up paying more to be seen in a hospital-based practice.

This payment system is the same whether you go to a tertiary care teaching hospital like Massachusetts General Hospital or a tiny 98-bed community hospital.

As an aside... for any physicians employed by a hospital, it behooves you to consider this differential payment in terms of how a hospital determines your salary and productivity. Do they consider ONLY the physician fee schedule or do they also take into account the outpatient prospective payment system?

I should also mention that Congress is considering abolishing the outpatient prospective payment system for clinic visits only. Click here for more info.

Source:
Same Doctor Visit, Double the Cost. WSJ 8/26/12

Hospital-Based Practice Versus Physician Private Practice. Fauquier ENT Blog 1/21/12.

Elimination of Differential in Medicare Payment for Clinic E&M Services Furnished in Hospital-Based Outpatient Departments Proposed. Martinedale 12/10/11

Medicare rules for hospital-based clinics. American College of Surgeons. Vol 87, No 4

Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System. Congressional Research Service. 8/6/2010

American Girl Doll Gets Hearing Aids

The American Girl doll company now offers hearing aids for their 18 inch doll models only through their Doll Hospital. Thanks to Tampa Bay ENT who shared this information.

Unlike humans who are able to obtain many different styles of hearing aids, only BTE (behind-the-ear) style is available for American Girl dolls.

Interesting, the medical services offered through the Doll Hospital is MUCH more impressive than what can be offered for humans. Services beyond hearing aids include new heads, new bodies, eye replacements, and limb replacements.

Though we do not offer hearing aids for American Girl dolls, we do offer the full array of hearing aids (selling, repairing, adjusting) for humans from Oticon, Phonak, and Widex.

100% Patient Satisfaction Scores

What if I told you this 100% patient satisfaction score was due to a survey of only two people... that I personally picked?

Welcome to the big bad world of patient satisfaction scores.

Often (well... pretty much all the time), I come across an article, bulletin posting, or meeting where patient satisfaction scores are announced... but no background information to back it up. HOW many people completed the survey? HOW were the people selected? WHO administered the survey?

HOW many people completed the survey?

The number of patients who actually completed the survey is very important. Mainly, because of the variance that may occur month-to-month as well as ease in manipulating the results.

Let's assume only TWO people completed the survey. The first month, both give me a thumbs up giving me a score of 100%.

However, the following month, another TWO people completed the survey, but only one gave me a thumbs up giving me a score of 50%.

NEWSFLASH!!! "Patient satisfaction scores plummeted 50% over a 1 month period of time!"

In order for meaningful interpretation of patient satisfaction scores, enough survey results MUST be obtained, especially when comparing scores across time.

HOW were the people selected?

Let's pick on the emergency room...

If I wanted to "pad" my results, I would tend to provide surveys to patients who had simple problems and who were seen quickly.

Child with an earache? Let's seem them immediately in Fast-Track ER. [Look in the ear! There's an ear infection.] Here's some antibiotics. Can you also complete this survey?

As opposed to...

55 year old narcotic-addicted patient with fibromyalgia demanding a prescription for 500 percocet pills for his chest pain. I would probably not want this patient to fill out the survey. Neither would the patient as he would probably toss it.

Granted these are extremes, but if performance bonuses are provided to departments with the best patient satisfaction scores and the ER staff were the ones providing the surveys, one can easily manipulate the results in their favor.

WHO administered the survey?

As mentioned above, survey results can be manipulated depending on who provides or gives the survey, ESPECIALLY if money is involved based on the results of the survey.

In order for survey results to be meaningful, a third uninvolved party should be the one to administer the test.

Survey Fatigue

Now even if the survey was done dispassionately and adequate number of surveys were completed, there's still the problem of survey fatigue...

What's that?

I don't know about you all, but I get about 3-4 letters per week and at least one phone call per day asking me to complete a survey on my car, toothbrush, tater tots... etc. You name it... there's a survey for it now.

Now add how many questions are asked... Hopefully one so it's quick.

But also HOW the questions are asked (yes/no versus a scale of 1-10).

As a person completing a survey, if I had my way, there would only be one question that is a yes/no question.

The more questions there are and if they are scaled rather than yes/no, the less likely I'm going to do it.

Now add if you are sick and in pain... How likely are you going to actually complete a 50 question survey on a scale of 1-10???

Probably not...

In fact, it's probably only going to be healthy individuals who tend to give better scores giving a skewed result.

Also, given the survey fatigue I and I bet most people have, it will be a rushed completion without much thought given. The default being five stars all the way down (I may not even bother to read the questions).

A decent way to look for survey fatigue is to have 2 randomly buried questions where rather than 5 stars being the best, 1 star is the best. Surveys where everything is 4 or 5 stars INCLUDING the reversed scale questions should be thrown out.

Summary

Whether good or bad, patient satisfaction scores can be VERY misleading if not completely wrong...

I should also add that whenever money is involved, NO test is going to be 100% accurate due to cheating that WILL happen one way or another.

I predict that this problem is going to get MUCH worse because health insurances will soon base how much reimbursement hospitals and physicians get based on patient satisfaction scores. We are talking about millions and millions of dollars.

Just read about the "no-child left behind" from the Bush era where student test scores influenced teacher pay leading to teachers allowing cheating on tests.

Costs of Surgery... How Is This Calculated?

So I have blogged about this topic a few times in the past, but there still seems to be confusion regarding the costs of surgery.

As mentioned in the past, the cost of surgery is broken down into basically 3 separate charges:

• Surgeon's charge
• Anesthesia's charge
• Hospital's charge

So... after surgery, a patient typically will get 3 bills; one each from surgeon, anesthesia, and hospital.

At least in the United States, the three charges are completely separate from each other to the point that anesthesia will have no idea what the charges for the surgeon as well as hospital will be.

Same goes for the surgeon... the surgeon will know his charges, but will have no idea what the charges will be for anesthesia and the hospital.

Even if the surgeon demands to know what anesthesia and the hospital will charge for a surgical procedure (s)he will perform, a specific charge will not (can not) be provided in the United States typically.

Why is that?

If I am going to perform for example, a tonsillectomy, why can't anesthesia give even me the surgeon a specific dollar amount of what anesthesia will charge? Why can't the hospital administration provide me the hospital charges?

Here's why... or at least part of the reason why in the United States...

Surgeon's Charge

The surgeon's charge is set. For a given surgeon, his/her charge will remain the same regardless of time or difficulty of the surgery. It may be different between different surgeons... but for a given individual surgeon, it will always be the same for a given procedure.

For example, if the surgeon's tonsillectomy charge is $250. It will remain $250 whether it takes 15 minutes or 3 hours. It will remain $250 if the surgery was technically difficult or a piece of cake.

So, the surgeon's charge is easy. It is what it is.

The harder question to answer is what the anesthesia and hospital charges will be...

Anesthesia Charges

Anesthesia charges on a per time basis (in increments of 15 minutes) on top of a "base" charge that depends on the surgical procedure.

For example, let's say a given anesthesia group has a base charge of $500 for tonsillectomy.

Let's also assume this particular anesthesiology group charges $500 per 15 minutes of anesthesia.

SO... if the surgeon performs a tonsillectomy and it takes the surgeon 30 minutes to perform the procedure, the anesthesia charge will be $500 base charge PLUS $1000 for the time ($500 per 15 minutes) for a total anesthesia charge of $1500.

If it so happens that the surgery takes only 15 minutes... than the anesthesia charge will be $1000 ($500 base charge plus $500 for the 15 minutes surgical time).

In other words, for the SAME exact surgical procedure, the anesthesia charges may be different for different patients depending on how long the surgery takes.

Hospital Charges

Different hospitals calculate their charges differently... but in essence, the hospital will charge whatever it cost them to allow the surgery to happen in their facility plus a nebulous "profit" factor.

SO, a given hospital charge will include the:

• Salary of all the personnel used in the surgery (surgical tech, registered nurse, circulating nurse, anesthesia tech, secretary, etc)
• Equipment used during the surgery (IV lines, needles, anesthesia tubing, masks, endotracheal tube, surgical equipment, etc)
• Medications used during the surgery (gases, IV drugs, etc)
• Facility costs expended during the surgery (electricity, water, oxygen, medical waste disposal, etc)

To take the example of tonsillectomy, the hospital charges will include all the equipment, medications, personnel, and facility costs utilized during the tonsillectomy surgery.

In Summary, the Cost of Surgery is... It Depends

Given anesthesia charges vary based on the time duration of surgery regardless of WHAT the surgery is as well as hospital charges which may vary based on how much was "expended" during the surgery regardless of WHAT the surgery is, the anesthesia and hospital charges are moving targets which roughly correlate with how long the surgery takes.

The surgeon can certainly state what their charges will be up-front because this charge is fixed, but anesthesia and hospital charges are NOT fixed and depend on a certain time factor regardless of WHAT surgical procedure is being performed.

Because of this time dependence, that's why anesthesia and hospital charges can not typically be obtained prior to surgery in most places.

That's also why most places can't (won't) post the total cost of surgery up-front.

Of course, if a given surgeon is very consistent and always takes 15 minutes to perform surgery and always uses the same exact equipment, than anesthesia and the hospital may be able to provide an "averaged" charge up-front.

It is also not uncommon that additional "discounts" may be offered based on a patient's income.

Some places like the Surgery Center of Oklahoma somehow persuaded the anesthesiologist, surgeon, and facility administrators to sit around a table and force an agreement on a fixed TOTAL charge for different surgical procedures. Once an agreement is made on a fixed charge for each, an up-front cost can be publicized... but this can never happen as long as anesthesia and hospital refuses to agree to a fixed charge and rather stick with a time-based framework to determine their charges.

Waking Up to NOT Just Major Colonoscopy Bills...

The New York Times published an article on May 28, 2012 regarding the high anesthesia charges associated with colonoscopy.

What people need to realize is that anesthesia charges apply not just to colonoscopy, but ANY procedure that requires general anesthesia... tonsillectomy, appendectomy, gallbladder surgery, ear tube placement in kids, etc.

With any procedure requiring general anesthesia, a patient is going to receive THREE bills... not just one which is what most reasonable people think.

1) A bill from the surgeon

2) A bill from anesthesia

3) A bill from the hospital

Sometimes the hospital and anesthesia charges are bundled into a single bill.

Often, patients mistakenly focus on the surgeon's charges thinking that's where their largest out-of-pocket cost is going to lie. However, the surgeon's fee is almost always the lowest of the charges.

Let's take a look at the New York Time's article...

The GI doctors actually performing the colonoscopy procedure got paid around $200. The anesthesia charges were around $2000 or 10x more (note that insurance coverage was an issue in this article and IF insurance did cover, out-of-pocket charges would have been significantly lower).

And than... if the procedure is done in the hospital, the hospital charges will often be around $5000 or 25x more.

These charges are similar to that found for many ENT procedures as well including tonsillectomy. (Of note, all insurances that we participate with... the anesthesia group I work with also participates with.)

On a more personal note, I recently underwent a general surgical procedure myself performed under general anesthesia in the hospital and got the following charges (3 different bills):

1) Surgeon's charge of $425 of which I owed $148.54 (difference covered by insurance)
2) Anesthesia charge of $1,400 of which I owed $140 (difference covered by insurance)
3) Hospital charge of $3,710.25 of which I owed $559.05 (difference covered by insurance)

Now if anesthesia did not participate with my insurance company, than I would have been fully responsible for anesthesia's full charge of $1,400. This situation is what the New York Time's article mainly focused on.

SO what is a cost-conscious patient to do?

Rather than focusing on the surgeon doing the procedure, the biggest cost-savings will occur negotiating with the hospital followed by anesthesia.

OR... avoid having procedures done in the hospital altogether to avoid hospital charges followed by avoid general anesthesia if at all possible and stick with local anesthesia alone. You will than ONLY have to deal with surgical charges which the surgeon should be able to inform up-front.

WHY do surgeons do procedures in the hospital rather than the office?

Beyond patient and procedural factors which may require general anesthesia, procedures may preferentially be performed in the hospital due to money. No big surprise there, but it may not be for the reasons people may suspect.

Let's take a real life example... balloon sinuplasty.

Balloon sinuplasty is an innovative minimally invasive surgical procedure to treat chronic sinusitis. Prior to 2011, this procedure was almost always performed in the operating room in the hospital though it could have been performed in the office.

Why?

The balloon used for this procedure costs around $2000 and is not reusable.

The reimbursement for the surgeon to perform this procedure was around $200+ depending on the number of sinuses addressed and insurance company.

SO... if balloon sinuplasty was performed in the office prior to 2011, the surgeon would have spent $2000 to do the procedure and than would have gotten paid only $200+ meaning a loss of ~$1800.

Why not charge the patient for the balloon device? Because it is called balance-billing and it is illegal.

So what is a surgeon to do if a patient desires balloon sinuplasty and yet the surgeon doesn't want to lose money?

You do it in the hospital... where the hospital eats the $2000 cost of purchasing the balloon device... and the surgeon still gets paid $200.

However, starting in 2012, insurance companies started reimbursing surgeons for the cost of the device which is why all of a sudden, balloon sinuplasty is now being performed in the office.

This type of financial calculation occurs all the time in medical offices.

Even a pediatrician's office where gardasil vaccination is often not offered... Why? Because the vaccine costs more than what the pediatrician will get reimbursed to give it.

Source:
Waking up to Major Colonoscopy Bills. New York Times 5/28/12

Australia Ends $500 Million Electronic Medical Records Initiative

First United Kingdom ends their $17 billion electronic medical records initiative in 2011 and now Australia follows suit after 6 years of trying to fund their HealthSMART health information technology project and projected costs went from $318 million to $557 million.

This Australian project was to have provided hospitals with software from Cerner, iSoft (now CSC) and InterSystems... the same system which also failed to be implemented by United Kingdom.

I said it before and I'll say it again... I'm not surprised.

And I would wager that the United State's own electronic medical records initiative HITECH signed into law in 2009 by President Obama will also fail similarly though perhaps not as spectacularly.

It's hard enough to get a group of doctors in one hospital to agree with a treatment plan let alone agree to a medical records system. The problem is exponentially more difficult when applying it to an entire country.

Physicians practice medicine differently... just like teachers have their own unique way of teaching kids. A method that may work for one doctor or teacher will not work for another. Even the method may change depending on how "busy" things are (teacher with a class of 5 kids versus 30 kids) so a doctor in a busy inner-city emergency room will have different flows and needs from an electronic medical records than a rural family practice with a sedate pace. Furthermore, the needs of a dermatologist is very different from a pediatrician. One can't expect a single EMR system to meet the needs of both perfectly just like one cannot expect a math teacher to use the same teaching methods as a singing teacher.

Forcing physicians to use a single standard electronic medical records without adapting to these realities is bound to fail no matter how much time, training, software, and hardware you throw at it.

A better alternative (my opinion), is to treat electronic medical records like the computers they reside on. There should be many different types of EMR systems just like there are MANY different types of computer models, speeds, makes, cost, sizes, etc.

However, unlike current EMR systems, in spite of who makes a computer and what operating system software it runs, it has standardized components... USB, Firewire, HDMI, VGA, BlueTooth, etc. as well as a universal communication medium called the "internet" that works with phones, computers, laptops, etc regardless of who makes it and what software it is on.

You would think that an EMR system given its digital essence would be able to easily communicate with other systems... but no... they don't communicate at all... which is why paper reports still exist... which are than scanned into the EMR.

Rather than the government (whether the United Kingdom, Australia, or the United States) dictating what physicians must do and mandating EMR initiatives, I believe the money would be much better spent on mandating inter-operability and communication standards. The free market will create the best EMR systems and physicians will pick the one that best meets their need.

The other more insidious side of EMR is the over-reaching health goal mandates which means well, but runs into the same problem of applying standards to all physicians. Take "meaningful use" set by the Centers of Medicare and Medicaid Services (CMS). One of the core measures of meaningful use is adult weight-screening and follow-up.

Now as an ENT specialist, I see patients specifically for earwax. Why in the world would I want to perform a weight-screening when all I want to do (and what the patient only wants me to do) is get earwax out???

Makes no sense.

Does it to you???

Sources:
Government dumps hospital IT system. ABC News 5/18/12
Victoria kills HealthSMART IT project. IT News. 5/18/12

If Computer Security Experts are Getting Hacked, Why are Hospitals/Doctors Expected to be Better?

As anyone knows from reading the newspaper recently, major computer security firms like RSA and Verisign have been hacked. Even the pentagon!

If companies that specialize in computer security get hacked, why are hospitals and doctors who do NOT specialize in computer security held to an even higher standard?

Criminal penalties against healthcare professionals and organizations are steep for computer data breaches at $100 per record with criminal penalties that can include fines of $250,000 and 10 years in prison.

Given such steep penalties, the assumption is that hospitals and physicians must be experts in computer and network security... even better than companies that specialize in this subject area... or can purchase one.

So who should healthcare organizations hire to secure their computers to avoid getting hacked as I can certainly tell you, they are most certainly not security experts?

Google? Symantec? RSA? Verisign? The pentagon?

They've all been hacked successfully... As such, how can we trust their security products?

The answer is simple... There is no company that can be contracted to provide bulletproof security.

The only way is to NOT use a computer at all!

So here's the interesting quandary...

The government is mandating hospital and physicians to transition to electronic medical records or start facing penalties for not doing so.

BUT, the electronic medical records must have bulletproof security or else criminal penalties and even jail-time can be had for any breaches.

With these mandates, the only thing doctors and hospitals can hope for is to not get noticed by hackers. Either get punished for not using a computer or get punished for not having a security system even better than the pentagon.

Source:
Why the security industry never actually makes us secure. CNET 3/3/12
HIPAA Violations and Enforcement. AMA

Hospital-Based Practice Versus Physician Private Practice

The other day, an astute patient of mine asked what the difference is between a physician who works for a hospital (hospital-based practice) versus a physician run private practice.

After all, a patient still sees a physician in either case...

Is there an actual difference from a patient's perspective???

Assuming all things equal whereby a private practice physician and a hospital-based physician are equally competent and the supporting staff for each are both equally good (such assumptions are debatable in some circles, but will be ignored here), it all comes down to money.

When a patient sees a private practice physician, the fee schedule only incorporates payments to the physician.

When a patient sees a hospital-based physician, the fee schedule not only incorporates physician payments, but also additional payments to the hospital.

Now, the patient doesn't pay what insurance covers in either scenario, but typically there is a copay or coinsurance payment that the patient is responsible for that typically is 20% of the total charges.

Here's an example using the Medicare fee schedule from 2002. I elected to provide "old" 2002 data as this information can be found easily and corroborated, but rest assured, the numbers are starkly different and perhaps more lopsided today. Medicare was selected as it is the bar to which all other insurance plans are typically based on.

In a physician run private practice, the only charges that are incurred is from the "Physician Fee Schedule". In a hospital-based practice, a patient incurs not only the physician fee schedule, but also additional charges based on the "Outpatient Prospective Payment System".

As you can see, the physician fees are slightly higher in the private practice setting compared to hospital-based practice... BUT, given the additional hospital charges involved with a hospital-based practice, the patient ends up being charged more per service for a simple clinic visit ($16.48) than if they had been seen in the private practice office ($10.06).

The cost differential for the patient is far worse with any procedures ($62.62 versus $342.47).

For the same exact procedure or service, a patient automatically ends up paying more to be seen in a hospital-based practice.

This payment system is the same whether you go to a tertiary care teaching hospital like Massachusetts General Hospital or a tiny 98-bed community hospital.

As an aside... for any physicians employed by a hospital, it behooves you to consider this differential payment in terms of how a hospital determines your salary and productivity. Do they consider ONLY the physician fee schedule or do they also take into account the outpatient prospective payment system?

I should also mention that for 2012, Congress is considering abolishing the outpatient prospective payment system for clinic visits only. Click here for more info.

Source:
Elimination of Differential in Medicare Payment for Clinic E&M Services Furnished in Hospital-Based Outpatient Departments Proposed. Martinedale 12/10/11

Medicare rules for hospital-based clinics. American College of Surgeons. Vol 87, No 4

Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System. Congressional Research Service. 8/6/2010

What Makes a Successful Hospital - Where Are the Tweakers???

First off, I don't have a business degree (in fact, I'm a MBA drop-out) nor a degree in hospital administration (does chairing a hospital committee count?), but I do have an opinion (don't we all) in light of having co-founded a bioinformatics company (iCORD, LLC) in the past based on a patent developed during my surgical residency... But I also admit that the company was ultimately unsuccessful if one measures success in terms of monetary profits, but I can say I succeeded in that my now defunct company's "product" still lives on at Duke University Medical Center.

It is perhaps my mixed bag background of a few victories and even more failures that I learned a thing or two about what it means to become better... it is what I call evolutionary tweaking or to put it more bluntly... whining and doing something about it. But let's stick with the "tweaker" euphemism.

Tweakers are annoying and may be a thorn in any administrator's side, but they produce results. They tinker and tinker in an attempt to improve and better a situation they consider a problem whether it be an engine, a computer program, or an entire production system.

Based on Isaacson's biography about Steve Jobs, he had it in abundance... even on medical care and devices during his last days.

Apparently, in his very last days of life, he went through 67 nurses before he found 3 he liked. He also refused to wear an oxygen mask due to a perceived poor design until he personally reviewed 5 different mask options and picked the one he liked best.

I'm certainly not promoting a culture where every patient, nurse, doctor, and administrator should start whining and complaining about everything. The hospital would shut-down.

BUT, there should be a culture where incremental tweaks are not only allowed, but encouraged with the expectation that many ideas will fail with monetary setbacks. However, just like survival of the fittest, the cumulative evolutionary cycles of keeping successful ideas and tossing ones that aren't will lead to a better organization over time... continuously and cheaply.

Home run ideas should not be the goal. Batting consistent singles (or tweaks) are...

There are systems to describe this process: PDSA (Plan Do Study Act), Toyota Production System, Just-In-Time Production, Deming Wheel, Shewhart Cycle, Control Circle, etc.

Now I certainly am not the first to suggest this concept to hospital settings. In fact, I've seen PDSA posters tacked on a wall in hospital physician lounges in the past.

However, I have observed great variances in how different hospital systems incorporate this "controlled whining" into their culture and administration.

Some embrace this process wholeheartedly and have succeeded in abundance. Others give lip service and designate the "tweakers" as whiners to be shut-up with bureaucratic red-tape, offensiveness requiring peer-review, or worse.

Employees and staff are a hospital's greatest assets both in terms of knowledge and production services. A hospital can either embrace trying to unlock the knowledge of what it already possesses or it can stifle them by punishing those who try to "tweak" thereby sending the message to everybody else to stay in the background... passivity being the rule... or voluntarily leave (or get fired).

The long-term success of a hospital system depends on how well it utilizes ALL its resources including not only encouraging an idea a hospitalist physician may have about telephone communication (allowing for faster patient care), but also trying to discover the knowledge trapped in a janitor's head who just might know how to thoroughly clean a hospital floor in half the time (saving time and money), but is too afraid to say anything.

Adapt or perish. History is replete with immensely successful companies that failed to adapt and are now either bankrupt or nearing death... Eastman Kodak, Tower Records, Borders Bookstores, etc.

And how does a hospital adapt to avoid non-existence? Continuously tweak... even when things are going well. USE all your assets with all guns blazing rather than smothering them.

Celebrate the tweakers!!!

Singer George Michael With Tracheostomy

Reuters reported today that singer George Michael suffered from severe pneumonia and underwent a tracheostomy during his hospitalization. A tracheostomy is when a hole is made in the throat for a patient to breath through.

Here is a video of what his trach surgery may have looked like.

Michael apparently was in the middle of a tour when he became ill requiring him to cancel upcoming shows.

A tracheostomy is often performed whenever a patient has been intubated (tube down the throat) on a breathing machine for a prolonged period of time.

For more information on trachs, click here. Watch a video of a trach being performed here.



Reference:
Gaunt George Michael says "fortunate to be here" Reuters 12/23/11

Doctor Distraction Happens... It's Mandatory!

I admittedly snorted out loud when I read a New York Times article  earlier last week regarding increased physician distraction due to electronic devices, especially with the advent of the smartphone with its emails, text messages, calls, and other alerts that ping intermittently throughout a typical work day.

There is no question that electronic devices distract physicians as the article pointed out... But that's like complaining about a leaky faucet when there's a flooded basement and a hole in the roof.

The bigger problem that should be mentioned is hospital bureaucracy which probably creates just as much if not more unintended distractions for physicians and nurses.

What many patients and lay public may not realize is that there is a TON of paperwork that goes into the care of a patient. Regulatory bodies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that accredits hospitals have made it mandatory in many cases though I suspect hospital administration often carries it a step above and beyond what is truly necessary.

What all this "mandatory" paperwork means is that nurses are calling physicians all the time just so they can check a box on a form... and there are a LOT of boxes to check.

Take a simple ear tube placement. A procedure that takes about 1-2 minutes to perform under sedation in the pediatric population.

It takes about 15-20 minutes to fill out all the nursing and physician forms (whether paper or electronic medical records). When the surgery actually begins, the nurse is too busy filling out even more forms rather than paying attention to the surgery... and often the surgery is already over... and the nurse is still busy filling out forms.

Talk about distraction... a registered nurse has been relegated to being a mere secretary rather than helping (or paying attention) in the care of a patient.

I recently asked a nurse how much time they spent on actual patient care versus how much time filling out forms during a typical shift.

It saddened my heart when I was told 60-70% of a nurse's time is spent on filling out forms (whether notes, chart documentation, medication reconciliation, etc) and only 30-40% on actual patient care. This time disparity was not always true in years past.

OR... ask any physician how many times they get called during a typical day because some form or paperwork was not completed or needs completion or just remind to get it completed by nurses who themselves are the main individuals who suffer under the crush of mandatory documentation in a hospital setting.

It is irritating to say the least to get a phone call during the middle of an operation, say dissecting a tumor off the facial nerve during a parotid cancer resection, by someone who wanted to remind me to sign off on a medication list on a patient I've already provided prescriptions for.

Another classic experience of mine was when the anesthesiologist had trouble intubating a patient who started to suffer a severe lack of oxygen. I was immediately called to the bedside and performed an emergency tracheostomy.

Of course, the nurse (well indoctrinated in form completion) involved in the case immediately instructed me to STOP performing the trach and to get consent as per the regulations... which is true 99% of the time... but never mind that. Heaven forbid we now can't check that little box that states "consent obtained prior to surgery." But in the interest of patient care, I did suggest that it would be better if the patient lived with an unconsented trach rather than died due to time spent obtaining consent.

Though electronic devices may be considered a "distraction" analogous to a mosquito buzz that comes and goes, one must not forget the avalanche of paperwork which is a much more pervasive and insidious distraction that DELIBERATELY takes attention away from the care of the patient. I understand the need for documentation, but at some point when the documentation itself dominates the majority of heathcare rather than the actual administration of care, there's something fundamentally wrong going on.

It's probably why medical missions are so gratifying to participating nurses and physicians where 90%+ of the time is in actual patient care.

Reference:

As Doctors Use More Devices, Potential for Distraction Grows. NYT Dec 14, 2011.

Portable CT Scanner

Portable X-ray machines are commonplace... but a portable CT scanner?!!

I saw this article by MedGadget about a portable CT scanner introduced earlier this year that can be wheeled around in the hospital made by NeuroLogica.

When looking up more details, the company makes not just one portable CT scanner, but FOUR different portable machines:

• BodyTom: Portable whole-body CT Scanner
• CereTom: Portable CT Head scanner
• OTOscan: Portable CT Sinus scanner
• inSPira HD SPECT: Portable SPECT scanner

Pretty amazing.

Though the whole-body CT scanner seems a bit big to be easily moved from hospital room to hospital room, it is comparable in size to portable fluoroscopy equipment currently in use. The other models are quite a bit smaller.

Realistically, I think the CereTOM will be the big winner as CT scans of the head is probably the most ordered CT scan in the hospital, often ordered to evaluate for stroke, head injury after a fall, sinusitis, facial fractures, brain tumor, seizures, etc, etc, etc. In many of these situations, the patient is fairly immobile and it just may be easier and faster if the CT scanner is brought to the patient rather than patient wheeled to a stationary CT scanner.

ENT Position Available With Our Practice

Our practice is looking for a board-eligible or board-certified otolaryngology-head & neck surgeon sometime in 2013-2014 time frame with guaranteed income that first year followed by partnership.

We are located in Northern Virginia about 45 minutes directly west of downtown Washington DC and is run by Dr. Chang in solo practice. The practice itself is located on hospital grounds situated in the lovely tree-lined rural city of Warrenton, VA where one can even see the Appalachian mountains from our office. Many city amenities are available within a short 15 minute drive but without the traffic and hassle of big-city congestion.

Interest in general otolaryngology is a must with sub-specialty interest even better. Some facts that may be of interest:

• Full-service ENT office with audiology, hearing aids, allergy testing, and allergy shots
• Near-monopoly services in terms of ENT and allergy in the region. 1 of only 2 otolaryngologists in the county… no otolaryngology services in counties to the West. 1 of only 4 allergists in the county 
• Office fully on electronic medical records
• Office on hospital campus (one office and no satellite offices to cover)
• Hospital and Radiology fully on electronic medical records & PACS, all accessible via iPhone and iPad
• BrainLAB image guidance available
• Office will be moving to a brand new medical office building (still on-campus) in near future with in-house ambulatory surgery center. Ownership opportunity available for both.
• Aggressive social media participation
• Semi-rural, small-town environment
• Call would be 1:3 (with calls rarely occurring after hours)

If there's any interest, please call or email!

For more information about our practice, check out our practice website!

Please note...

We will not deal with recruiters.

Updated Google App Translates English<->Spanish Conversation in Real-Time

Earlier this month, Google released an incredible app (only for the Android market at this time) that can translate English to Spanish as well as Spanish to English in REAL-TIME allowing for a somewhat stuttered conversation with translations on the fly.

At this time from what I hear, it can understand English pretty good, but understanding Spanish is not quite as good. With time, I expect the accuracy to improve to the point that potentially, this app can replace human translators in the exam room.

What a boom to breaking down language barriers in the hospital and clinic. At this time, I have to enlist the help of the AT&T translation services.

One can only hope that it'll become available on the iPhone soon!

Surgery Costs for Self-Pay Patients

Surgery is expensive... there are no doubts about that. However, there are a few things a patient without insurance who desires surgery can do to minimize the costs as much as possible. Before going into cost-cutting measures, you first need to understand where the costs come from.

In rank order, the costs of surgery come from (highest to lowest):

• Hospital Charges (MOST expensive charges)
    a) Use of OR Room
    b) Paying the Circulating Nurse
    c) Paying the Scrub Nurse
    d) Paying for the medications used during surgery including anesthesia
    e) Paying for the OR room cleaning
    f) Paying for administrative overhead
    g) Use of surgical instruments including cleaning/sterilization after use
    h) All disposable used for the surgery (ie, masks, drapes, wires, IV tubing, gauze, etc)
• Anesthesiologist Fees (excluding anesthesia medications)
• Surgeon's Fees (LEAST expensive charges)

The hospital charges run into the many thousands of dollars (typically charges start at around $3000 and goes up from there). The surgeon's fees can be as low as $100 to around $1000 depending on the surgery. The anesthesia's fees are between the hospital charges and the surgeon's fees (yes... anesthesiologists are paid similarly or more than the surgeons per case).

So now that you know where the costs come from, what are some ways to reduce them? Please be aware that the surgeon has no control/authority/influence over the anesthesia and hospital charges which the patient needs to individually deal with each separately.

• Have the surgery done in an Ambulatory Surgery Center if possible. Oftentimes, the costs are almost 50% lower than the same surgery done in a hospital. If possible, the hospital charges can be completely avoided if the surgery is done in the surgeon's office.
• Ask the hospital about self-pay discounts/payment plans.
• Ask the surgeon about self-pay discounts/payment plans.
• Ask about further fee discounts if the total cost is paid all at once up front in cash rather than a payment plan.
• DO get referred by a free clinic if your income level qualifies you. Free clinic referral pretty much means (for most patients), the care including surgery will be provided completely for free. Fauquier County residents have one here.
• If possible, request only local anesthesia which is cheaper than MAC anesthesia (twilight anesthesia) which is cheaper than general anesthesia which is the most expensive.
• Request medication samples (ie, antibiotics for after surgery).

Patient Experience Just As Important As Clinical Expertise

I read with great interest an article in the New York Times "How Does Your Hospital Room Make You Feel?" regarding how a patient room... how a hospital appears... private rooms... may play just as important a role in where a patient goes for treatment as the clinical expertise of its doctors.

Indeed, amenities are a critical part of the patient experience and possibly even a more valuable component of patient-centered care as reported in the New England Journal of Medicine. A patient’s nonclinical experience inspires clinical productivity, drives improved clinical outcomes, and improves overall patient satisfaction.

Not that such reports are a big surprise. It's something I think all major non-healthcare corporations have already realized for decades. Just walk into any Abercrombie & Fitch or Toyota car showroom. Such businesses hit all of our senses to the 10th degree... There's the visual stimulation of models (human or otherwise). Popular music playing in the background to stimulate the ears. Lovely perfume smells in a clothing store or fresh leather in a car showroom to stimulate the nose. And oh yes... freshly baked cookies or candies to bring some zing to the taste buds.

How can you NOT like what you see/hear/taste/smell??? And, buy some things along the way given you have been stimulated into such a good mood?

Indeed, it's surprising why hospitals weren't the FIRST institutions to maximize the senses to bring peace to mind/body/soul and... to also provide medical treatment.

SO... it is with great satisfaction that our practice is affiliated with a hospital that subscribes to the importance of these non-clinical factors. Fauquier Hospital has:

• Private patient hospital rooms
• Family and friends can drop by any time, day or middle of the night
• Food that's actually good
• Patient friendly architectural features including:

• built-in sleeping accommodations for family members
• carpeted corridors and additional windows
• lamps have replaced overhead lighting
• halls have been carpeted to keep down noise or are finished in faux wood for a warmer feel
• community artwork hangs on the walls
• barriers between patients and staff, such as those sliding-glass windows that close nurses off from patients and the public, have been removed
• elevators for patients and the public are separate
• no constant paging over the intercom system, either; instead, unobtrusive music plays all the time.

• Also, a culture fostering patient care is presented.

Come check out Fauquier Hospital here!

Read the NYT article here.

Read the New England Journal of Medicine Article here.

Positive Patient Feedback

Dr. Chang received a bonsai tree from Fauquier Hospital for having received positive patient feedback for the past 4 consecutive quarters. How nice!

Read other patient testimonies here.

Fauquier Hospital VIPeds Medical Camp Program on Channel 9 News

It was quite cool to see Fauquier Hospital's innovative VIPeds Medical Camp program featured on Channel 9 news. This unique hands-on program is for teenagers to learn more about the health profession and opportunities found inside a hospital.

Local teens learn to apply a cast, to harvest a cornea (I personally have no idea how to do that!), to suturing a wound closed. No ENT related procedures however...

Check out the video segment here.

The Perfect Computer for Healthcare and Electronic Medical Records

So I've been using computers in the healthcare setting for over a decade now. First at Yale than Duke. I've been thru the Veteran's Affairs Medical Center using Vista (New Haven, CT; Durham, NC; Asheville, NC; and Portland, OR). I've been at 5 different community hospitals on both the West and East Coasts. I've used all the different flavors of electronic medical records (EMR) in all these different locations/settings. I'm now using (not by choice) NextGen, Meditech, Rcopia, and PACS currently in the office, hospital operating suites, and inpatient settings.

Throughout this time period, I've used desktop computers, handhelds, laptops, netbooks, and tablet computers. I've even tried to cobble together a semi-functional iPad able to access all the different EMRs I need on a daily basis (read blog about this here).

What I discovered is that the perfect system (in my mind) is ALMOST there... just not quite yet. Maybe in the next few years, it will exist because all the pieces now exist! The bad news is that it does not exist RIGHT now.

So, here's my dream machine and the reasons. I hope some computer company is paying attention!

To understand how this all fits together, one needs to envision how my office works right now. There's a desktop computer in each exam room. Patients are taken back by a nurse and information inputted into the desktop computer. Than the computer is locked and the nurse leaves. The physician than soon follows, unlocks the computer, and then proceeds with further history, exam, and plans treatment which all gets documented in the computer. If tests are ordered (ie, hearing test, blood draw), the doctor leaves and sees another patient while the tests gets done before coming back. As such, the computer stays in the room with the patient. One can envision that there is a lot of back and forth into and out of an exam room movement of nurse, doctor, and patient. The computer gets locked every single time. Furthermore, I need EMR access when seeing patients in the hospital as well as during surgery.

First the Hardware:
• A tablet touchscreen (with no physical keyboard) 12 inches diagonal. That size hits the sweet spot. Any larger and the size itself becomes unwieldy to constantly move around as well as heavy by the end of a day. Any smaller and the screen real estate becomes so small to become inefficient. 12 inches diagonal also allows the possibility of an actual full-size virtual keyboard on the screen with adequate screen left-over to see what's going on.

My experiences with the iPad virtual keyboard was mixed (given it is somewhat smaller than full-size). I CAN do it and I did do it... I just didn't like it to the point I relied on a wireless bluetooth keyboard.

• Bluetooth technology and WiFi are a MUST because...

• With this tablet computer, one can dock it without wires or connector pins (similar in concept to Motion Computing JR3400 with its FlexDock). The docking station allows for use of regular USB keyboards and mouse along with direct ethernet wired connectivity. My dream machine docking station and tablet would communicate with each other using bluetooth or some other alternative short-range wireless technology which makes direct physical connection unnecessary. This is important, because I would have the docking station in each exam room. When I leave the exam room, I would have the option of taking the tablet (and therefore the screen) with me. The constant connecting and disconnecting of current docks is quite the pain given it requires an actual physical connecting port as well as precise placement. With the constant connecting and disconnecting, it opens the possibility for breaking as well.

What would be even cooler would be if the tablet charges when in its docking station using inductive charging similar to how a Philips Sonicare Toothbrush recharges.

Why do I even want a docking station? Several-fold. Ergonomics... I like the screen at my eye level. Also, I can still see the patient while typing away. If I depended on the virtual keyboard like on the iPad, I'm looking down which is not patient-friendly as well as a pain in the neck (from looking down). Also, though I guess I can learn to type fast on a virtual keyboard, I think I would still prefer the physical full-sized keyboard if given a choice. Furthermore, though wireless WiFi for all internet connectivity is nice in principal, it does introduce potential security problems as well as speed issues (wired ethernet in my experience is still the most reliable and fastest way of communication along with being secure).

However, WiFi connectivity is still important as pretty much every medical setting has WiFi and so one does have continuous high speed wireless access. Also, it would allow me to read a little bit of what's going on with a patient before walking into an exam room (I would load up the patient's chart using the touchscreen before walking into the exam room and docking the tablet). I just do not want to always DEPEND on WiFi.

A WiFi tablet touchscreen like the iPad is also great as one can BRING your office with you where-ever you go like the hospital and operating room without bringing a keyboard, mouse, etc. It's all self-contained. It's intuitive. It's all neatly packed into a simple, elegant tablet touchscreen that's highly portable and usable.

• Proximity security whereby the computer tablet "knows" you are right there. When you are no longer around the computer, it automatically locks. When you come back, it recognizes you and it automatically unlocks, all occurring invisibly to me without requiring me to actually do anything. I HATE the fact that I have 4 different userids with 4 different passwords to access the various EMR programs. Though I try to, I do not always remember to lock the computer 100% of the time. It should be all automatic. Does the technology exist? It sure does... It's called Single Sign-On for one userid and password that unlocks it all. And Xyloc by Ensure Technologies to allow for proximity recognition using RF technology. All I ask is that this technology be built-in to the hardware!

In a clinic where I'm constantly moving around where the tablet may not always be with me, due to HIPAA and HITECH, the computer needs to be secured. Though I try, I can not always remember 100% of the time to lock the computer. And same goes for my medical assistants. The security should be automatic, invisible, and secure.

The problem with biometric verification like fingerprint scanning or even ID card swipes is that I have to REMEMBER to do it. And the mere fact of doing it is aggravating because I would have to do it SO many times in a given day.

• Sturdy construction. The tablet is going to move around... a lot... It needs to stay working after being dropped from at least a height of 3 feet.

Which Brings Me to the Software:
What can I say? I LOVE the intuitive and simple interface of the iPad. Now, there's a few things I would tweak about it to make it MORE relevant in the healthcare setting.

• Multi-Tasking is a must. As I literally use Meditech (hospital EMR), NextGen (clinic EMR), Rcopia (electronic prescribing software), and PACS (radiology viewing software) all day long swapping back and forth even with a single patient encounter, I need to be able to easily jump between all these programs without shutting down the others. From what I understand, this functionality on the iPad will soon be reality with the release of the iOS4 operating system later June 2010.

• I constantly move back and forth among Meditech, NextGen, Rcopia, and PACS all day long. As such, having a few physical programmable buttons on one side of the screen on the edge would be wonderful which I could just press and it would take me immediately to my program of choice. Keyboard shortcut works, but imagine what touch-strokes would be required when I'm using it in pure tablet touchscreen mode...

• Apps already exist to connect via Citrix, Remote Desktop Connection, or screen mirroring... so I would just use those programs. If I was prone to unrealistic wishful thinking, I would ask for a single EMR program that incorporates Meditech, Nextgen, Rcopia, and PACS, but I do not forsee anything like that happening for decades (if ever). So, I'm going to stick with what is possible.

• A "tablet pen" is 100% optional and not necessary for use... Tablet touchscreen would be used predominantly using a finger(s) just like on the iPad. Personally, I do not foresee myself ever using a tablet pen. It's just one more thing that can get lost.

That's pretty much it! Is that so much to ask for???

Related iPad and MediTech Blog Articles:
6/12/10 iPad Use In the Medical Clinic and/or Hospital For the Surgeon Doctor
9/8/10 Dr. Chang Featured in Magazine Article on Using iPad with MediTech EMR
9/20/10 UPDATE: iPad and MediTech Electronic Medical / Health Records
10/12/10 UPDATE #2: iPad and MediTech Electronic Medical / Health Records
10/25/10 New Video Produced on Using MediTech on the iPad!

iPad Use In the Medical Clinic and/or Hospital For the Surgeon Doctor

To read what I consider the perfect computer for healthcare, click here.


UPDATE 10/25/10: Watch video of using MediTech on the iPad

To give a little background, I am a ENT (otolaryngology-head and neck surgeon). I see patients in all sorts of environments including the hospital, operating room, and outpatient clinic. In the hospital, I use MediTech and PACS while in the clinic I use NextGen. Admittedly, I was not entirely convinced the iPad would ever be useful in this varied medical setting which utilized different EMR platforms when it first came out earlier this year.

However, several developments have occurred that has since changed my mind due to the ingenuity of app developers and other progressive technology that allows the iPad to connect with hospital and outpatient clinic electronic medical records (EMR) regardless of operating system and security settings.

The information provided here is based on using an Apple iPad 16GB model with WiFi only ($499).

Software

Foremost of these evolutions is the iPad/iPhone apps now available that allows for EMR access. To give some background, I use MediTech and PACS in the hospital and NextGen in the outpatient clinic. In order for me to access all electronic health records, two iPad apps are necessary:

1) LogMeIn: Wonderful app that allows the iPad to remotely control a Windows (or Mac) desktop computer anywhere in the world. The iPad app itself is $29.99. The LogMeIn desktop software (free) also needs to be downloaded to any desktop you want to access/control with the iPad. In essence, the iPad takes control of the desktop which you can see on the iPad screen. As such, any software including EMR programs like MediTech, NextGen, or indeed any other application (via Citrix) on the desktop, can be opened and visualized on the iPad. Click here to download this program.

The pictures below show MediTech as well as PACS being opened on the iPad using LogMeIn. The keyboard you see is a bluetooth keyboard wirelessly connected to the iPad (more on this below).

Of course, this method produces a slow response time as one is jumping through different networks to obtain medical records access (iPad --> LogMeIn --> Desktop --> Citrix --> Medical Records).

A more elegant solution would be direct Citrix/VPN access to the medical records (iPad --> Citrix/VPN --> Medical Records). Unfortunately, the hospital/clinic would need to upgrade their software in order to make this happen (which has not yet happened at my hospital). For those curious, the iPad software is called Citrix Receiver and is a FREE app download! Click here.

2) WinAdmin or Jump: Of course, if one is able to access medical records using terminal services (rather than citrix, VPN, etc), there's a perfect app for that called WinAdmin or Jump. Just punch in the same info you do to open terminal services on Windows and viola... the remote desktop appears on your iPad! Both  apps are iPad optimized and costs $8.99 for WinAdmin or $19.99 for Jump. Click here to download WinAdmin or here to download Jump. You can see a screenshot (to the right) where NextGen Master IM was opened up on the iPad using WinAdmin app.

The difference between Jump and WinAdmin are several-fold. Jump has better mouse usage controls (there's a mouse!), better virtual keyboard (including Tab, Esc, Function keys), and allows for external keyboard text entry. WinAdmin does not (so far). But I guess you get what you pay for! Having used both, I personally prefer Jump (originally purchased WinAdmin because it was cheaper).

SO, I basically use Jump to access NextGen which is accessible via terminal services and I use LogMeIn to access MediTech (as well as PACS viewer). As soon as direct Citrix access is available (should the hospital upgrade their Citrix software), I would change to Citrix Receiver instead of LogMeIn in a heartbeat.

Hardware

The keyboard is essential as I do a great deal of free-typing which is not easy (to type very fast) when using the iPad's virtual keyboard. As such, a bluetooth wireless keyboard is important for me to allow fast touch-typing. There are plenty of wireless keyboards out there... the one I use is the Apple Wireless Keyboard. However, this keyboard isn't perfect as the keyboard is bigger than the iPad and as such, needs to be carried around separately. I never even bothered getting the iPad Keyboard Dock as one MUST orient the keyboard vertically (in order to dock the iPad) which is not preferable when I used the iPad for accessing electronic medical records. For just that reason, I always keep the iPad screen locked in horizontal orientation.

As such, for me, the next piece of the iPad implementation for medical use is hardware. Here, I am most eagerly awaiting for the ClamCase which is supposed to be available for sale in Fall 2010. The "ClamCase" offers the perfect package in my mind:

• A nice case for the iPad for transportation

• A wireless bluetooth keyboard for freetyping

• Full use of the iPad as a standalone device in case I don't want to use the keyboard

• Keyboard fits within the case where you want it (so it can be opened up like a laptop)

What the ClamCase does that no other device offers is a wireless bluetooth keyboard BUILT-IN to the iPad case in a single beautiful package!

Here's a YouTube video showing the full features of the ClamCase:



Hopefully, it will live up to its hype and I will be basking in heaven using the iPad to do pretty much everything whether in the hospital, operating room, or clinic. Once multi-tasking becomes available with the next OS Upgrade (iOS4) later this month, that will be most awesome as than I can have NextGen, MediTech, and Safari up with Rcopia (the electronic prescribing program I use) all up and running simultaneously and I will be able to just switch among the programs without losing anything.

For now, I'm trying it out on a limited basis before ditching the old system (desktop computer in each exam room) and using iPad exclusively.

Will keep those interested updated on my experiences over time...

In meantime, read what I consider the perfect computer for healthcare here.

Related iPad and MediTech Blog Articles:
6/19/10 The Perfect Computer for Healthcare and Electronic Medical Records
9/8/10 Dr. Chang Featured in Magazine Article on Using iPad with MediTech EMR
9/20/10 UPDATE: iPad and MediTech Electronic Medical / Health Records
10/12/10 UPDATE #2: iPad and MediTech Electronic Medical / Health Records
10/25/10 New Video Produced on Using MediTech on the iPad!