The Regulatory Mess
Hal Grotke, MD, asked, “Should I Trust the Government?” on the President’s Page of the March 2010 Bulletin of the Humboldt-Del Norte County Medical Society.

Statutory laws and regulations have been hard on us, to say nothing of case law. Thanks to Medicare, if we choose to provide medical care for people over 65 years old, or with permanent disability, we must submit bills electronically. Of course, most of us have people for that, but we still do it by extension. Thanks to HIPPA we can no longer tell a spouse, without specific permission from a patient, that a patient has herpes simplex virus infection. Thanks to new regulation from California Department of Managed Healthcare, if we cannot offer an appointment to a patient in a prescribed timeframe we may have civil liability. And thanks to MICRA if our doctor harms us with some egregious neglect we are severely limited in how much we can be compensated financially. (I include that last one a bit tongue in cheek.)

All of those laws and regulations, with the possible exception of electronic billing, exist because of large scale and repeated failure to do the right thing. None of those laws and regulations work entirely the way they were intended anyway. The greatest failure of those specific laws, to my knowledge, is the second P in HIPPA. Although there is now a federal mandate for COBRA coverage for people leaving a job at which they were lucky enough to have employer provided health insurance there is no regulation of premiums. Very few recently unemployed people can afford to buy such coverage. As for the new California regulation regarding timely access, the loophole for doctors is that we can simply document why we think the patient is unharmed by delay. The much bigger loophole for insurance companies is that they are not the ones being regulated. If there is an insured person in the area who needs to be seen it doesn’t matter that the insurance company pays so little that no doctor is willing to see a patient with that insurance. This regulation only applies to patients with insurance specifically regulated by DMHC and to physicians who contract with such health plans. As far as that regulation is concerned we can still delay indefinitely scheduling patients who are uninsured or have indemnity coverage such as Medicare without a managed care supplement…

How did we get into this mess in the first place?

Read all of this article, and the next item, at http://www.sonic.net/~medsoc/images/bulletins/2010-3 MARCH BULLETIN_web.pdf.

Obesity Rates
In the same Bulletin, Ann Lindsay, MD, Humboldt County Public Health Officer, discussed obesity.

According to data from the Centers for Disease Control and Prevention the national obesity rate has held steady for the past five years. The new data are based on health surveys involving height and weight measurements of 5,700 adults and 4,000 children.
The results shows 68 percent of adults are overweight, with African American having the highest rates of obesity, followed by Hispanics and Whites. About one-third of children aged 2 to 19 were overweight, with the percentage of extremely obese children steadily increasing…. We have yet to see the leveling off trend in Humboldt County.

The GIGO Factor
Karen S. Sibert, MD, Associate Editor of the CSA Bulletin wrote on “Peering over the Ether Screen; The Electronic Medical Record: Garbage In, Garbage Out” in the Winter, 2010 issue.

My first patient of the day was a congenial man in his 50s with a history of prostate cancer and radical prostatectomy, scheduled for replacement of a defective penile prosthesis. The history and physical in his chart was a pleasure to read because it was printed and legible, as opposed to the handwritten scrawls we often encounter. Imagine my surprise, however, at reaching the section about this patient’s previous surgical history, and finding that he was supposed to have had none. I looked twice to make sure I was reading it correctly. No prior surgery. Impossible, of course — he had had both prostate surgery and the initial penile prosthesis placement. Then I realized the obvious truth: We were sabotaged once again by the fatal ease of data entry error in a computerized record…

Worse still is the potential propagation of errors in the patient’s medication list. The other day we had two patients in preop with the same, quite common, first and last names. Looking over the computer printout of my patient’s medications and seeing Keppra listed, I asked him if he was doing well on Keppra and how long it had been since he had a seizure. He looked puzzled. He didn’t take Keppra, he said, and to his knowledge had never had a seizure. We quickly figured out that the nurse had merged his med list with that of the other “John Smith.” That was the easy part. The hard part was fixing the mistake. It turns out that once the nurse “closes out” and prints the record, apparently it takes an act of God to undo it. In the meantime, Keppra remains on the med list…

Back to my patient with the penile prosthesis: Once I had determined that everything in his H & P was going to require independent verification before it could be relied upon, I took a longer look at the internist’s recommendations for perioperative care. I include them verbatim:

“Pt is at low risk for surgery. Please avoid shifts in Blood Pressure and Volume. As is true with all surgery the anesthesiologist should mind the blood pressure as this will reduce any unknown cardiac risk the patient may have. A profound anemia would add further risk, which this patient has no evidence of. Should heavier than expected bleeding occur, please keep Hct over 30 for further cardiac risk reduction.”

Although I don’t know for sure, I would bet money that this internist had a check-off list on his computer with someone’s idea of appropriate advice for the anesthesiologist. How would I ever have managed the case without it? Is this really the quality of information we can expect from a completely paperless system? Computers, after all, don’t generate content; they only store it and make it available for retrieval. At the end of the day, if you put garbage in, you’ll get garbage out, and any time we thought we saved will be spent sorting through the trash.
The entire article by Dr. Sibert is available at http://www.csahq.org/pdf/bulletin/sibert_59_1.pdf.

On Breathing
The Spring 2010 issue of Sonoma Medicine is devoted to breathing. This is part of the introduction by pulmonologist James Gude, MD.

The word pneuma, literally meaning “that which is breathed or blown,” was used by ancient philosophers to describe the soul or vital spirit of a person…

Breath and breathing matters are the themes of the contributors to this issue of Sonoma Medicine. As a consultant to five rural intensive care units in Northern California, I value the role of respiratory specialists. Indeed, four of the top 10 rural ICU diagnoses involve respiratory distress: acute and chronic respiratory failure, community acquired pneumonia, chronic bronchitis and emphysema (COPD), and asthma.

All four of those ICU pulmonary diagnoses involve smoking…

All his comments, and the entire issue, is at http://www.scma.org/magazine/?vol=66&num=2.