Wednesday, July 29, 2009

The Internet and Emergency Care...

I suspect that the use of the Internet has saved many lives. With extensive search engines like Google and Wikipedia, people have easy access to information (not necessarily accurate information). There is a tremendous amount of medical information sites, some with great information and others with not so great info. Nevertheless, people use the Internet every minute of the day.

It is not uncommon for me to see a patient in the ED who comes in and says, "You know, I just didn't feel right, I developed some chest discomfort or indigestion, and I went on the Internet and the site suggested that I seek out medical attention." Well in general, that's a good thing since, for example, many woman do not have typical symptoms of a heart attack such as "crushing chest pain" but rather fatigue which they downplay and do not often seek timely medical attention. Clearly, when someone is having a heart attack or MI (myocardial infarction), "time is tissue" meaning the shorter the duration of seeking medical care the better chance of saving heart muscle. And, that is no different for strokes or "small" strokes (TIA's). With strokes, many people are not educated on the symptoms and often neglect them until it's too late.

On the other hand, the Internet has also driven up the cost of health care for ED visits. Frequently, I'm scratching my head at 4 a.m. when a patient presents with a variety of symptoms, and I'm trying to figure out exactly what is going on. Why did the person decide to come to the emergency department at 4:00 a.m. with a constellation of symptoms that don't make sense other than generalized anxiety. I often ask the question, "I'm curious, the way you're feeling started at 10 p.m. last night, what changed for you to come in at 4:00 in the morning?"

Often I hear, "I couldn't sleep, so I went on line and plugged my symptoms in and I thought I had cancer!" Something that wouldn't change at 4:00 a.m. but adds to the patient's anxiety.

Where in the world could you get a reasonable answer to your medical concerns 24/7. Try calling your physician at 4:00 a.m. to tell him or her of your symptoms and let them know you think you have cancer...see what the response is...sometimes it's "go to the ED" (so they could go back to bed)!

Friday, July 24, 2009

More Expensive Medical Care & Duplication of Testing...

So I spoke about the poor integration of information systems in medicine...and here's even more. The technology is out there to convert radiology imaging and other ultrasound imaging into an electronic format. Some hospitals have that capability. You no longer have to get a copy of an x-ray and stick it on a view box, rather it's transmitted to a computer terminal and you view it on a screen. Systems can be very sophisticated where you can essentially connect via secured Internet sites with encrypted information) to view these studies in your office or even in your home called teleradiography.

The biggest issue however, is if you are not a part of a hospital (meaning you don't have privileges as a physicians) you do not have access to the information. There is a total lack of integration. There is also a concern that somehow, people will get sensitive health care related information, and inappropriately disseminate it. Where this is true with any electronic data, there are enough mechanisms in place to assure security.

Let me give you an example of how ridiculous this is for the EM physician. Mr. A presents to the ED at Hospital B with a chief complaint of chronic headaches for the last few months on a Friday at 6 p.m. He states he was called by his doctor, physician C, who had ordered an MRI of his head and was told that he has an abnormality and needs to go to the hospital - perhaps a brain tumor and he has had the MRI at hospital D's outpatient department. You call physician C, but physician E, a covering doctor, does not know anything about the patient or the results and cannot get in touch with physician C. You call hospital B, only to find that they cannot give you the information because the MRI department is closed. It closed at 5 pm. So, what are stuck doing - you can either repeat the MRI, which is an extremely expensive test and not easy to get even in your hospital at 6 p.m. or you perform a CT scan of the head (less expensive but still expensive and has a small risk for radiation exposure). Hours later you get the results of the CT scan - a brain tumor, you still need the results of the MRI but that can wait tonight since you have a diagnosis and the patient needs to be admitted to the hospital for a biopsy and treatment.

And you ask, why did the patient not go to hospital D's ED after the call...the answer, "because your hospital has a better reputation" but I lived closure to hospital D to get the MRI and it was easier....Of my God, not easier for the poor physician working in Hospital B's ED trying to care for the poor patient (who by the way, will ultimately probably die within a year despite chemotherapy, radiation, and surgery) all further expensive care with a low yield for survival.

Again, do you really think that physicians enjoy working this way?

Wednesday, July 22, 2009

Robust Medical Information Oxymoron!

Sometimes policy makers and elected officials are right on...and one of the truths to medicine is "there is too much diagnostic testing performed." There are many reason for this...medical liability...lack of research to guide physicians into best practices, comfort level of the physician, pressure from patients, the lack of an integrated records system, etc.

Today, I want to focus on the latter - the lack of integration of medical records. It amazes me that there is some "computer in the sky" or "big brother" who has all my financial reports, balances, the ability to go to a bank on the east coast and withdraw money from the west coast bank, etc. What we are lacking in health care is that same ability (at least as a nation) for health records. Most physicians are in private practices and these practices may be a solo practitioner or small groups (at least in the majority of the country). Most hospitals are nonprofit entities with small systems, again the majority in this country. Despite what you may think, the profit margin (as a provider) is not much and therefore people have limited funds to integrate an electronic record.

What this means, is that there is limited financial resources (and lack of motivation) to have a well organized record keeping system that is in an electronic format. The financial industry can transmit much information electronically and the systems have a unified way in which a combination of systems can operate (thus, the above bank analogy). But many hospitals and the majority of physicians do NOT have electronic records. In fact, it was only in the last few years that my hospital incorporated a partial electronic record. Not only is there a lack of systems, but many of the systems (within a hospital) don't have the capability to speak with one another. I know for those involved in business, it is hard to believe, but when a hospitals profit margin is only 1-2% per year, you can see there is little revenue or incentive to modernize!

Add to this the ablity to integrate with independent practitioners' records in the community is a disaster. Again, it wasn't until a few years ago could physicians in my area get outpatient lab results that were performed at the hospital.

Think about it, Mrs. A cannot have labs done at lab B because her insurance company doesn't participate so she has to go to lab C but lab C sends the results by mail and there is no lab interface directly with Doctor D, so he not only can't get the results (unless he calls - an added step) but no one else caring for Mrs. A has access to the records (especially when Doctor C's office is closed) and Mrs. A does to the ED at Hospital D...get the big picture! And do you think that most emergency medicine physicians like to practice this way...more to follow tomorrow...

Tuesday, July 21, 2009

Is the ED Cost Efficient?

Emergency medicine is a 24/7/365 day of the year service. The visits are not scheduled and ED's cannot hang up a sign on Friday afternoon that says, "Closed at 5 p.m. will open on Monday at 9:00 a.m." Our society has grown to understand that it is the only place in the nation where they can get around the clock assistance for "unscheduled and emergency care." And, other physicians, (both primary care and specialists) have found that out too. They also send their patients to the ED when they cannot provide for their patients' care during office hours or after office hours when the office is closed.

That said, ED's have been accused of not being "cost efficient" and "expensive." By the nature of the business, there is a basic operating cost to staff and operate an ED - equipment, personnel, etc. Barring volume, there is a certain amount of fixed costs regardless of whether there are 10 patients seen in a day or 20. Obviously, as volume increases, costs increase for personnel and equipment. So is it fair to say, that it is inefficient? I don't think so, since the ED is now the FRONT door to the hospital. Most hospitals have over 50% of the admission enter through the ED.

In fact, no longer do many hospitals have direct admissions, where patients come sick directly from home or a nursing home. Rather they come to the ED first to have further diagnostics testing and initiation of their treatment prior to being admitted to an inpatient bed. Years ago someone presented to the ED with abdominal pain, they may have had lab studies, x-rays and maybe admitted for observation or consultations and over the course of 2-3 days have a CT scan, further consultations, and other testing. But now, the same patient comes in and can spend 6-8 hours in an ED but the work-up is streamlined and a decision made to either safely send the patient home, send them home for further outpatient management and testing, or admit them to the hospital for further care that they cannot receive as an outpatient. A far cry from what happened years ago. Actually most of us would consider that MORE efficient and cost effective avoiding an even more expensive hospitalization.

Monday, July 20, 2009

Optimizing Visits to Blogs

Still trying to figure out how to optimize exposure for blogs, if anyone has any suggestions I would like to hear from you (as long as you are not some sales person selling software or a spammer). I thought perhaps people would want to know what really goes on in ED's but maybe that's just not the case.

People assume that when they need emergency care, ED's will be there for them. Unfortunately, not all ED's are alike. Although many physicians who work in ED's are board certified in the speciality, many are not.

Recent staffing studies suggest that there will be a continued shortage of emergency medicine physicians. Emergency medicine is a relatively new specialty (only 40 years old). The "baby boomers" who started emergency medicine are moving on to other things or are retiring.

Interestingly, the majority of patients go to smaller and midsized ED's that may not be staffed with board certified emergency medicine physicians. That means the physician may still be trained in some other field - surgery, internal medicine, family practice, etc. Where I don't mean to degrade the capabilities of those who have practiced emergency medicine for a far longer time than I, I think the public needs to know this. That said, I have seen less than optimal care provided by physicians who are board certified in many specialities so board certification does not guarantee excellent care but it does imply specialized training in the field.

Many hospitals require physicians to be "board certified" but that does not mean that the person working in the ED be certified in emergency medicine. For the educated consumer, you need to find out what percentage of those physicians in the ED are "board certified or residency trained in emergency medicine." Where you don't have this luxury to shop around when you have an emergency, it helps to know what hospitals near home fall into this category. You may be surprised. And the size of the hospital may not determine the percentage of EM trained physicians!

Sunday, July 19, 2009

Undocumented Immigrants & Health Care...

As I spoke of in the past, EMTALA federal legislation applies to all patients presenting to the ED. This includes the care for the estimated 11 million undocumented immigrants who are a part of our population and add to the burden of the uninsured. What is interesting is that no national Health Care Reform plan takes on this issue to date (or maybe it does because of the purposeful exclusion of these patients).

Where I don't want to get into a philosophical diatribe about whether to insure undocumented immigrants, what does the public expect ED's to do when these patients arrive? Probably the same we do now....treat them and expect no payment for services. At least (for the most part) one does not have to worry about malpractice since most attorneys will not touch these cases since there is very little room for economic damages - the guy planting your shrubs or mowing your lawn or the woman cleaning your house or the person behind the counter at McDonald's can't claim millions of dollars in damages if he or she is disabled. Our society really is twisted!

Our elected officials in state and federal government are smart. They can avoid this issue (so they can't be labeled as bigots and worry about loosing votes if they refuse to insure undocumented immigrants). Congress and policy writers know that these people can at least get "free care" in any Emergency Department in the nation off the backs of physicians, hospitals, and other providers, including insurance companies and other patients secondary to cost shifting! Who said Congress was stupid?

Saturday, July 18, 2009

Bad Things Happen...

I saw a 50 yo Hispanic gentleman who came into the ED because his blood sugars were running high. He was recently treated for a "bronchitis" and placed on an that time his sugars were high and he had not been compliant with his diabetes medication. He had no insurance and paid for his medications himself. He started back on the medication but his sugars were still high and wondered what was going on.

He also was complaining of continued shortness of breath with some wheezing. I repeated his chest x-ray which showed a large mass (probably cancer) and a new pneumonia secondary to the tumor. I then performed a CT scan of his chest which confirmed my suspicion. The man had a tumor that had also spread to his lymph nodes in his chest. I was shocked since he was relatively young, a nonsmoker, and no history of any occupational exposure to explain why he had the tumor.

He was subsequently admitted for further treatment. He, of course, has no insurance so I will not be paid and the hospital will receive some money from the state to cover some expenses. All the other physicians who care for him will not receive any payment either. I'm not complaining about the money, I at least made the unfortunate diagnosis and was able to get him help. Perhaps he has a lymphoma that may respond to treatment. My point is...did his lack of insurance lead to a delay in diagnosis and if he had better care would the diagnosis have been made earlier? Who knows...