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Justin Moore, MD, has thoughts.

I'll encourage patients to record medical visits on their phones...IF I can use the recording as my documentation

May 3, 2018

In my telemedicine days, I complained constantly about the dual data entry I was forced to do. "Dual" in that I was seeing patients through a platform that could easily have recorded the visit, but I was still obligated to generate a note for billing purposes. I don't mind writing notes; I write pretty comprehensive recommendations on platforms like RubiconMD. It's the tedium of being a data entry clerk and recording things that no one will ever read that's tough. Notes are for doctors to communicate: What problem are we collectively trying to solve? What changes are we seeing in lab results or symptoms or tumor size?

For that communication to happen, the notes need to be pretty short, including some objective measures and beyond that, basically just the assessment and plan. No doctor has ever--ever--reviewed the Review of Systems from another doctor's note. Ever. But we're required to record an ROS so that we can bill under E & M (Evaluation and Management) codes, introduced to much criticism in the mid-1990s. Ditto the family history; when I see an endocrine patient, I sometimes have very specific questions about genetics and family history that are astonishingly unlikely to be included in a note from a primary care doc or, say, a general surgeon. But I dutifully click through the multiple screens that it takes to enter the information, just so that other docs can ignore it. This process, combined with the poor design of most electronic health records, is a primary driver of physician burnout, according to a 2013 RAND analysis. The assessment and plan is, I'm confident, the only part of the note that is consistently read by other docs. That's why, back in my salad days of old-fashioned transcription, I put the A/P at the top of my note. Docs could read it first, and then they could look at whatever other parts of the note they needed to only as-needed.

Notes increasingly are for patients, too. Open Notes, a project originally started in Boston kinda sorta over the objections of docs, has proven popular with patients and with providers. Patients like having access to the chart (duh). But I think the actual recording of the visit, like in the video above, may serve a better purpose for the patient, who can go back and review the doctor's words. The written note, conversely, may be a better place for the patient to record corrections or to report new symptoms. 

The "Snapchat for medical visits," as some people are calling apps like Medical Memory, gives me the cold shivers. That comes as no surprise to anyone who has bumped up against my fear and loathing of social media. But even now, without the aid of dedicated software, patients surreptitiously record the audio of a large number of visits (as much as 15% of patients, according to one cross-sectional study. Why not allow docs to use the patient recording (with both patient and physician consent, and with both having access to the recording) to account for the majority of the documentation? In such a model, the physician would simply have to record an assessment and plan?

It's reasonable to wonder how the recording could be used for billing, since coders historically go through written notes and check off various elements of the exam. But I'm confident that most of the complexity of the visit could be ascertained from the content of the assessment and plan; it would require no more coaching (and far less implicit encouragement of "chart buffing") than what coders do with residents and docs now.

In practice management Tags progress notes, medical memory, billing and coding
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Docs, you can get paid for ambulatory blood pressure monitoring

April 3, 2018

But it's not easy:

In practice management Tags blood pressure, ambulatory blood pressure, self-monitored blood pressure, heart disease, american heart association, american college of cardiology, stroke
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Pssst...wanna hear about quality improvement strategies in team-based hypertension care?

March 1, 2018

Then click here.

HTN Team strategies.PNG
In practice management Tags hypertension, team-based care, heart disease, american heart association, american college of cardiology, blood pressure, self-monitored blood pressure
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How do we engage practices in quality improvement?

January 18, 2018

From a 2017 grant meeting. Enjoy!

In practice management Tags hypertension, diabetes
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Not much food in this swamp.

Not much food in this swamp.

Links for Friday, December 29, 2017: food swamps, happiness from QI, and the persistence of ineffective treatments

December 29, 2017

So long, food deserts. Helloooo, food swamps

...food swamps had about four unhealthy options for each healthy one. Food swamps were a strong predictor of obesity rates—even stronger than food deserts were. The relationship between food swamps and obesity was especially strong in areas where people lacked both their own cars and access to public transportation.

See primary paper here.

Bob Badgett has thoughts on happiness and quality improvement

Screen Shot 2017-12-29 at 3.24.48 PM.png
Screen Shot 2017-12-29 at 3.35.53 PM.png

The Dunning-Kruger effect (which applies to docs) is the phenomenon in which difficulty in recognizing one's own incompetence leads to Inflated self-assessment. That is, the worse you are at your job, to some extent, the higher you rate your ability to do that job. Uplifting stuff when we think about management. 

Why do doctors keep recommending treatments that don’t work?

Tough question that Eric Patashnik does a good job of summarizing in a manageable length. We're all victims of our own status quo bias:

In the US, even modest reforms to use taxpayer money to fund research to learn what treatments work best, for which patients, have engendered controversy. Republicans famously charged that the establishment of the Patient-Centered Outcomes Research Institute (PCORI) through the Affordable Care Act, would lead to the creation of “death panels.” The politicians made that argument even though the agency only funds studies and was given no authority to make policy decisions or payment recommendations. PCORI has yet to have a significant impact on clinical practice. It faces a sunset date of 2019, and its future remains unclear.

In medical literature, links to health, practice management Tags food swamps, food deserts, happiness, quality improvement, Dunning-Kruger effect, heart disease, status quo bias, medical rituals, efficacy
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Collaborative practice agreements from the physician's perspective

December 1, 2017

Many thanks to Dr. Spurlock for helping us out. 

In practice management Tags collaborative practice agreements, pharmacists, hospice and palliative care
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How do we engage physicians in quality improvement? Not with money or guilt

October 23, 2017

I was asked to give input to the Kansas 1422 in-person meeting last week. I couldn't make it in person because of another speaking engagement, but I recorded some thoughts. Enjoy!

In practice management Tags quality improvement
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Just kidding. It's free. 

Just kidding. It's free. 

Your ticket buys a whole seat, but you'll only need the edge

October 20, 2017

I'm in Reno County talking about the future of healthcare in Kansas on Tuesday, October 23 at the Sand Hills Event Center. Beeee theeeeeerrre!

In practice management
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We should be using more out-of-office blood pressure readings

August 31, 2017
In practice management, medical literature Tags blood pressure, hypertension, self-monitored blood pressure, ambulatory blood pressure, heart disease, american heart association, check change control
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Should a pharmacist be a bigger part of your practice?

August 29, 2017

Conflict of interest disclosure here: I receive some grant funding indirectly that works to get pharmacists and docs into collaborative practice agreements (CPAs).

But if the video above makes you think your practice ought to be using more pharmacy brainpower, take a look at the video below on how to establish a CPA:

 

 

In practice management Tags pharmacists, collaborative practice agreements, team-based care, medical education, medical rituals
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