Sunday, July 1, 2018

What's the Good Word?


(Here's another missive from CDI land, in which I get to use The Osmonds, Diane Rheim, Gal Gadot, Ed McMahon, and testicles in the same article.)

We’re all about language in CDI World, which is probably why I fit in.  I’ve always been kind of a Vocabulary Nerd, with an occasional spell of Grammar Guy thrown in for good measure.  This is why the song “I’ll Be There” by the Jackson Five.  If you know the song, you’ll recall that twelve-year old Michael Jackson croons in his most plaintive pre-pubescent voice:

“If you should ever find someone new,

I know he’d better be good to you.

“Cuz if he doesn’t

I’ll be there.”

It’s a great sentiment, right?  Because if your new boyfriend is mean to you, you’ll want to fall back on a guy whose closest companion for years was a chimp named Bubbles (who is, according to Wikipedia, now living a quiet life at the Center for Great Apes in Wachula, Florida, where he is said to “enjoy painting and listening to flute music”).  But it’s horrible grammar.  There’s no way to doesn’t is a form of the verb “is” or means “to be.”  If he isn’t good to you, that’s one thing.  But if he doesn’t?  You should stay away from Michael as well, if he can’t figure out why that sentence is so very wrong.

(On the music front, Vocabulary Nerd admits to a certain admiration for The Osmonds, who managed to fit the word “facsimile” into their ballad “Love Me for a Reason,” though Grammar Guy notes it was followed by a dangling participle.  You learn to take the good with the bad.  Plus they’ve got great teeth.)

Here’s a language thing a little closer to home.  As all of us in CDI know, specificity is our friend.  That being said, coding rules recognize that things in medicine are not always cut and dried, and that there is significant fuzziness in everything we do.  We don’t always know what’s causing a problem, but we can make pretty good guesses.  So the Rules of the Game allow a clinician to use words like probably, likely, and possibly to describe what they think underlies and clinical problem even if they don’t know for sure.

There’s a little bit of hair to be split here, however.  (Not mine, in which case there’s a lot.)  My colleague Dr. Douglas Campbell notes that we really should not use the word “possible.”  His contention is that you should have at least a 51% chance of being right before being certain enough to code a clinical diagnosis as being present.  So if “probably” and “most likely” suggests that level of certainty, words like “possible” that suggests less than a 50% chance of being right shouldn’t be used.  After all, anything is possible.  There’s a zero point zero zero zero zero zero zero zero one chance that both Gal Gadot and Ed MacMahon will appear at my front door tomorrow with a check from Publisher’s Clearinghouse.  (Even less so now that Ed’s dead.)   So how can you code with certainty anything that’s less than halfway likely?  Or, as Dr. Campbell put it:

“See that three-day-old taco sitting on your desk? I’d possibly eat it, but I probably wouldn’t.”

The clinical term that always drove me nuts was “appreciate.”  In medical school we were told that we appreciated a heart murmur or some other physical finding.  But did we really?  According to definition, if you appreciate something you “recognize the full worth of” or “are grateful for” something.  So who really appreciates a murmur?  I have heard a lot of heart murmurs, but I have never appreciated one.  I have never been so moved by the whoosh of some blood fighting its’ way through a narrowed channel, nor by the splash of plasma thudding back into the chamber from whence it came.  I have yet to recognize the full worth of a mid-systolic breeze, to completely and utterly envelop myself in the moment.  I have never called my parents to relate the experience to them, have never pulled a sweetheart aside and, in a tender moment, told her that while I have absorbed the full value of the murmur it’s significance is nothing compared to my love for her.  Nor have I been uniformly grateful for the opportunity to listen to a murmur, not for the career in medicine, not even for the trust of the patient in permitting the intimacy of the physical exam…no, I’m usually just trying to figure out what it is I’m hearing because my cochlea have been poisoned by years of monitors with alarms  and bells and from listening to Diane Rheim on NPR, and I’m also trying to figure how just how close I have to be to hear anything if the patient is hygiene-challenged.  We should not say we appreciate heart murmurs unless we really mean it.  We don’t.  Just stop.

(Two, four, six, eight, what do we appreciate?  Aortic Stenosis!” exclaims the Cardiac Cheerleader, pom-poms flying in the Cath Lab.) 

(Speaking of things that drive me nuts, many of you are probably familiar with voice-activated dictation programs such as DragonSpeak.  One of the quirks of these programs is that every clinician seems to have words they slur or accent or are otherwise incomprehensible to the program.  There are two words of mine that seem to particularly vex the Dragon.  The first is “hospitalist,” which the Dragon keeps thinking is “hospice,” and given that a lot of patients admitted to the hospitalist probably need hospice this may be therapeautic guidance.  The other is cardiovascular, which every computer-aided dictation program I’ve ever used seems to think is “testicular.”  So there’s no telling how many female patients in my career have had testicular exams which revealed a regular rate and rhythm without murmur.  Nuts.)

The glamorous process of CDI chart review has added another term to my List of Infamy.  It’s the word “endorse.”  Have you seen this in your shop?  Apparently the new trend is to say that “the patient endorses shortness of breath and a history of CHF” instead of saying the patient has or said it.  I have no idea where this comes from, because when I look up the definition of “endorse” it goes something like this: 

1.         “To declare one’s public approval or support”, or

2.         To sign a check or bill of exchange to make it payable, or to accept responsibility for paying for it.

So when the patient “endorses” a history of shortness of breath and CHF, we might assume they are showing approval or support.  “I LOVE my CHF!  Best pulmonary edema ever!  I’ve got cardiomegaly!  HUGE cardiomegaly!  Bigger than China!  And my love my BNP…five figures!  My ejection fraction is so bad it’s the best of the worst!  Isn’t my LifeVest great!  Admit me for a little dobutamine and we’ll Make My Heart Great Again!  You should get some CHF too!  And I‘m paying my own bill!”

Come to think of it, that sounds familiar.  Wish I could place it.  Must be somewhere in that chart…

Saturday, June 23, 2018

Brief Thoughts


In my middle age I find myself paying an undue amount of attention to my groin. It's not that it didn't command my admiration and respect in my younger days.  Back then, it was more of a use or lose it kind of thing, the nether id screaming out for activity, to burst free from the suppressive superego that‘s my Hebraic legacy.  (This is a polite way of saying I wanted to be a man whore, as all honest men will confess to be their dream job, at least until they discover the joy of a committed relationship, the wasteland of divorce, or the burning sensation of...well, you get the picture.)  But now it's a more subtle, varied relationship, made full by the maturity of years and the fact that you buy “Dad Pants” on purpose because you treasure the space. 

The latest groin-centered experience (outside of a committed relationship, of course) occurred when I heard a radio commercial for Tommy John underwear.  If that name seems familiar, it’s probably because you’ve seen it in the sports pages. Tommy John was a pitcher for the Dodgers who suffered an elbow injury and was treated with a new kind of surgery that now bears his name.  Alas, the Tommy John of baseball is not the same Tommy John of underwear, which deprives the brand of a useful symmetry of things you can do with your hand and arm:  Pitch and…well…pitch.

Underwear had never really been much of a force in my life.  As a kid, you wore underwear with fun designs until you switched to boxers as things expanded and (hopefully) needed more room.   And that’s pretty much where it stays.  It’s not like women’s lingerie, where the moderately attractive can become alluringly hot through the art of selective concealment.  With guys, there’s no way to conceal anything (and no, a Speedo is nothing more than an abomination of nature), which is if a guy wants to look hot he has to dress up so that everything, even the back hair, becomes nothing but a dream.

Anyway, according to the ad, Tommy John underwear has a variety of notable features.  The one that piqued my attention was the quick-draw horizontal fly.  Personally, I’m not quite sure how horizontal equals quick draw.  The...ummm...generative organs are aligned on the vertical (the midline sagittal plane, if you must know), so it would make sense to align your access on the same plane. You need access, it’s right there waiting for you.  The few times I've worn things with a horizontal fly, access usually becomes something of a fishing expedition because the point of grasp is usually beneath the opening slit.  If this occurs in a public place, it undoubtedly looks to others as if you’re simply having way too much fun in the excretory endeavor.

But I'm also confused by the necessity of the quick-draw fly.  It would seem to me if you need it that quick, the moment has already passed.   To me, the concept of quick draw implies whipping it out for a quick shot, like your own personal Wild West single-barrel rifle (or pistol, or derringer, or cap gun, as the case may be).  But if you need to get it out that quickly before the mood goes away, that doesn't say a lot for the mood to start with; and if you need to get it out that quickly after hearing the word "draw" before the shots are fired,  that’s a Little Blue Pill issue that no underwear can solve.

Now back to your regularly scheduled blog.

Friday, June 8, 2018

Scamper and Flit


(Why can't anyone in Coding World get doctors to say what they mean?  It has to do with our nuts.)



Everyone’s probably seen the literature rack at the “Welcome Center” between one state and the next.  These are those small wooden fixtures containing stack upon stack of neatly slotted tourist brochures designed to lure the traveler into making just one more stop to see the pride of (fill in the name of your small town here).  Picking up these brochures has long been an addiction of mine, and there’s a whole tote bag in my bedroom closet full of information about sites I have yet to see.  I figure I’ve got about 15 years before someone calls Hoarders and puts me on TV.
So this is how I knew that I needed to stop one day in Greenville, Illinois, and take a selfie next to the World’s Largest Golf Tee.  Why WaKeeney, Kansas, is the Christmas City of the Plains.  Why Clark’s Fish Camp in Jacksonville houses the Nation’s Largest Private Taxidermy Collection.  And why I know about the White Squirrels of Olney, Illinois.
(For the record, the Olney brochure was picked up at the Beef House in Covington, Indiana, where my extended family went this summer after one of the most delightful funerals I’ve ever attended.  It’s just outside of Danville on Interstate 74.  Ask for the yeast rolls.)
I bring up squirrels because I recently had occasion to use the term in the context of CDI.  I was involved in a discussion about using CMI data on individual physicians to “call them out” on their performance.  As a CDI person, I know why this could be important.  If you have physicians who consistently underperform, it may be helpful to confront them individually, either privately to let them know you’re watching, publicly to utilize peer pressure, or with their supervisor to use third party influence to achieve CDI goals.  All of these are laudable and perfectly acceptable ways to address individual physician deficiencies.  (They will all also annoy the very physicians you’re trying to influence, but the decision to “call out” individual providers is a philosophical decision each CDI program makes for itself.)
From the physician side, however, our first reaction is to turn into a squirrel.  Marlin Perkins and Mutual of Omaha know that squirrels scamper.  They avoid, dodge, evade, and run for cover.  And when cornered, they give you a look so gosh-darned cute you simply can’t hit them with a bat no matter how times they’ve raided your bird feeder.  And when confronted with adverse information about themselves, doctors squirrel.
This behavior, of course, is not unique to doctors.  Every two-year-old knows how to do this, and is way better at it than adults because they can really work the cute.  But doctors are simply better at it, because we’ve been taught to do so in medical training as a way to avoid confrontation or being caught in the wrong, we have the intellectual heft to pull it off, and we’ve been doing it our entire professional life.
Let me give you an example from my own experience.  I’m an ED doc by trade and training, and I’ve sometimes been on the wrong end of those time studies looking at patient throughput.  My times were longer than the mean; in fact, close to the bottom of the group.  So what happened?  Did I take it to heart and resolve to change my ways?  Did I take a serious look at my practice style and gratefully acknowledge the input of my health care colleagues, especially those who issue the mandates but cannot actually do my job?
Of course not.  I squirreled. 
“Thanks for the information.  I’ve taken a look and I have some thoughts.  First, I work all nights.  As you know, there are no midlevel providers at night.  As a result, every doctor has relatively more patients to see per provider, and it’s well known that the more patients you’re caring for at any one time the more time it takes to care for each.  You’ll notice the data shows that all of us night shift doctor times are longer than the day shift people.  You’ll also notice that when I do get to the patient, I see them faster than anyone else on night sift.  That’s because instead of signing in for the patient when they get placed in a room, I don’t do it until I actually see them to avoid any errors in orders or documentation in the interest of patient safety.  (That phrase always gets you off the hook.)  And as I’m sure you know (you have to throw in at least a sentence or two of “collegial language”), patient flow in the ER is non-linear, so the fact that patients come in as a bolus in late afternoon and early evening rather then presenting to an empty ER early in the morning may skew the data as well.  Thanks again for the note, and I look forward to continuing our efforts in patient care.” 
I never heard anything again, and several months later they dropped the measurement altogether.  I imagine that I wasn’t the only squirrel in the forest.
So if you’re going to call out physicians, you have to be prepared for this.  They will find reasons to prove that you’re wrong, and you have to realize that sometimes they might actually be right.  For example, let’s talk about an orthopedic surgery group.  The metrics of some doctors look great, with high CMI’s; the CMI of others is much lower.  Call out the slackers, right? 
But not so fast.  What kind of procedures do the lower performers do?  If the higher CMI guys do hips and the lower folks do shoulders, they’re not really lower at all; they just have different patient populations.  The same can be said of a hospitalist who works nights and mostly does admits with only the rare discharges.  How about a cardiologist who does few admits but mostly consults?  The surgeon who doesn’t do his or her documentation but has the midlevel provider do it for them?  What does his or her CMI actually mean?
So how can you make sure that your “call-out” is really valid?  First, you need to make sure the patient populations are roughly the same.  You can probably do some fair comparisons on adult and pediatric hospitalists, as with decent volumes you would think that the “luck of the draw” would give you roughly equivalent groups.  But on the surgical side that’s harder to do, especially if you have only one or two  physicians who do a certain procedure at your hospital.  Having tools that provide some peer cohort facility measurements can be helpful as well, but be aware that the squirrels will still find ways to gnaw away at the acorn of data.    
You’ll also need to make sure that the documentation is really under the control of the physician.  I say this fully cognizant that from a coding view the physician is clearly the one on the line.  But in reality, much of inpatient documentation may be done by midlevel providers, and the physician simply adds an attestation and signs off on the note.  In an ideal world the doc would review every notation with a nit comb, but it simply doesn’t happen.  (Procedures make money, not post-op notes.)  So be prepared for the squirrel that says documentation is the midlevel’s problem, and rather than give a correction offer to extend your educational efforts accordingly.
Another trap to avoid is looking at short-term data.  There’s a virtual cornucopia of factors that can impact physician documentation, such as vacation, sick call, seasonal variations in patient populations, and simple physician fatigue.  I believe that a full three months of data is the minimum you should use to evaluate physician performance, but the more data you have, biannually or even yearly, the more reliable your trends will be.  More data over longer time frames adds validity to to your interpretations and tends to defuse some of the firestorms that result.  I’m personally very interested in statistics (Nerd Alert!), and I’ve even tried to apply the concept of statistical significance to identifying outlying providers based on their CMI compared with peers.  I’ve not found any sharp demarcations between our providers, but if a clear outlier is present the use of statistical techniques can help support your concern.
The bottom line is if you’re going to call a squirrel a squirrel, you had better do your homework first and be prepared for evasion, rationalization, and the like.  Squirreling is part of human nature, and doctors are particularly good at it.  Be prepared.  Oh, and don’t fall for the cute thing.  Keep the bat ready.
 




Friday, May 25, 2018


(Yet another missive from Coding World.  It turns out you can't place a diagnostic code into the medical record from a consultant's report.  Which means that if a consultant writes something on the charts, you have to ask the patient;s personal hospital physician if they agree before you can code it. Get it?  Got it?  Good.)


Memo from the Full Disclosure Department:



Lying behind my confident attitude, my devil-may-care good looks, and my abundant modesty lies a nerd.  I say this knowing full well what that entails, for a nerd is different than a dork or a geek.  According to OKCupid:


“A Nerd is someone who is passionate about learning/being smart/academia. A Geek is someone who is passionate about some particular area or subject, often an obscure or difficult one. A Dork is someone who has difficulty with common social expectations/interactions.”


Remember that OK Cupid is a dating website, designed to find people for people who don’t have people (and may be the unluckiest people in the world).  So they are morally obliged to put a positive, quirky spin on the terms.  Who wouldn’t want to date someone who’s passionate about learning or a master of a particular domain?  In truth, don’t we all have those little social hiccups?  Aren’t we all unique in our own way?  Isn’t that cute and endearing and wouldn’t you like to date me?


(I was actually okay with Nerd, as I thought I had no obsessions to speak of.  That is, before the Dental Empress brought up my thing with buying only hardcover books. And Legos.  And WKRP in Cincinnati.  And the fact that I cannot walk inside the house until I’m sure the interior light in the car is fully off, a trait which has caused the College Student to call me “Captain Paranoid” rather than the warmer epithet of “Dad.”)


I bring this up to indicate that after many years of attempting to be somewhat more normal, I’ve become comfortable with who I am….a middle aged guy who can admit to liking Barry Manilow and girls in the same sentence.  It also means that I can also freely express my admiration for Star Trek in the most unambiguous terms.  Which brings us to a small matter of CDI.


As we know, one of the rules of the coding system is that we cannot code off of anything except what’s written in the chart by the attending physician.  We can find useful information in nursing notes, nutritional consults, radiology reports, and pathology files, but we can’t code it unless it’s been noted by the attending physician.  As a result, we wind up sending queries to physicians asking if they concur with the tissue diagnosis of a pathology report, or agree with a particular finding on a CT scan or an MRI that might affect coding, reimbursement, and measure of illness severity.  These queries usually take the form of “Doctor McCoy, the pathologist noted the presence of Pon Farr in the biopsy sample.  Do you concur?  If you agree, please indicate this in your Progress Notes and Discharge Summary.”  To which in Klingon we most often hear in angry reply  “Im qar’a’ pathologist Qel“ or “Dammit Jim, I’m a doctor ,not a pathologist.” 

(Yes, I know you cannot see Pon Farr on a tissue biopsy.  But ponder the fact that you knew this and what it says about you.)


The simple fact is that doctors understandably don’t want to pass judgement on their peers, especially if it’s about something out of their own area of expertise.  It’s inherent within physicians to greet such a request with caution.  So if you ask them to agree or concur with something out of their ballpark, with medicolegal umpires officiating the game, they are going to eye that request with suspicion and may well let it go unanswered or actively reject the query.  (This is true unless it’s an ER doc, where anyone can level a shot and it’s considered fair game.  This is because most doctors did a month or two of ER during their residency and then went on to be SPECIALISTS…translated as “person smarter than you”…while the ER docs were not bright enough to leave.) 

I am not immune to this reluctance to confirm or deny that which I don’t understand.  This is especially true given that I made it through my pathology lab course in medical school not by detecting differences in the cells I was looking at under the microscope, but because I was able to memorize the shapes and colors on the stained slices of tissue slides we were issued for class.  (There was also this story going ‘round about students crawling through a ceiling in order to get a copy of an exam.  I’m sure it was just a rumor.)


Physicians don’t feel that way just about pathology reports.  We’re likely to encounter the same difficulties given any piece of conflicting or incomplete information in the record, whether it’s a radiology finding or a consultant note.  I’m not in a position to second-guess the other guy, goes the thought process, so why are you asking me to do so?  And yet clinically, we unwittingly do this all the time, in that we generally guide our clinical efforts dependent upon the findings and recommendations from our pathology, radiology, and consultant colleagues.  That certainly implies acceptance and concurrence.  We’re just loath to say so.  (Dr. McCoy told Kirk he was “a doctor, not a bricklayer.”  But he still found a way to patch up the Horta, and it still says something about you if you know what I mean.)


So in the end, it’s a matter of semantics, and there’s got to be a better term to use when we’re trying to get information into the chart.  If “agree” and “concur” won’t work, what can we use?  We need to look for words of agreement that don’t imply judgement but do imply active acceptance and integration into the plan of care.  Simply saying the results are “noted,” I think, doesn’t quite do it.  (I know this from experience; when nurses in the ER tell me that a patient wants more pain meds to go with their turkey sandwich and a bag of Cheetos, I usually say “Noted.”)  So perhaps we can ask, in a yes-or-no query, if the Attending Physician “acknowledges” the pathology report.  The common use of the word implies an active thought process and integration into the plan of care.  Maybe “accept” fills the bill, as it doesn’t imply an additional opinion but implicitly says the information is received, like a gift.  “Recognize” may not be as strong, but the word implies integration of the idea with reference to past events.


In order to improve our responses to these sorts of queries, we’ve got to quit asking doctors to second-guess their peers.  The right wording will help.  Unless it’s an ER doc, of course, in which case it’s all fair game.

*************************************************

Hi!  Lt. Commander Grammar Guy here, just beamed in from Deep Space Station K-7 to cause a little bit of Tribble.  Today’s agitation is with anything that calls itself (insert name of city) Memorial Hospital.  I get that hospitals can be named after important people who have passed on to the Gamma Quadrant.  But how do you name a hospital after an entire city unless that city has been wiped off the face of the earth?  I had a friend in Starfleet Medical College who was a graduate of Joplin Memorial High School in Joplin, Missouri.   We would go to Joplin to visit his parents and as far as I could tell, Joplin was still there.  So who was it named for, anyway?


(The Vulcan High Command, recognizing that that the Grammar Guy’s rant is illogical, has in fact discovered that Joplin was named for the Joplin Creek Valley, which in turn was named for the Reverend Harris G. Joplin, who settled upon its banks around 1840.  It’s my understanding that the Good Reverend has indeed passed on, swept up by the Great Bird of the Galaxy, so he could in fact qualify as a building’s namesake.  The Library-Computer also tells us that the nickname of Joplin is “JoMo” and that the City Motto is “The City that Jack Built.”  Which makes us want to neck pinch you all into unconsciousness.  It would be the logical thing to do.)


Thursday, May 17, 2018

"I'm Dr. CC. Get Your Medicine From Me."

By way of introduction, this post refers to specific terms in Clinical Documentation Improvement (CDI).  Hospital payment within Medicare is based on a scheme called MS-DRG's, or Medicare Services Diagnosis-Related Groups.  Within each group, the severity of a patient''s illness and needs for care can be further specified by documentation of Comorbid and Complicating Conditions (CC's) and Major Comorbid and Complicating Conditions (MCC's).  This post addresses CC's I wish we could use.  A couple of them are legitimate clinical issues...and the others?  I'll let you decide.  Meanwhile, Spotify's playing Clarence Carter...

A few weeks ago, I was giving a presentation to a group of surgeons.  I was talking with them about CDI, which as you might imagine is as near and dear to the heart of the surgeon as mindfulness is to Daffy Duck.  My comments engendered a surprising amount of discussion, the upshot of which was that maybe all patients should just be admitted to the hospitalists with surgical consults, as the hospitalists write more stuff anyway.  (True story.  And an idea not totally without merit.)

One surgeon asked an interesting question when I was describing what “makes” a CC.  “What about being homeless?  These people can’t keep their wounds clean, can’t get to follow-up care, can’t get their medicines.  And what about non-compliance?  Doesn’t that count for something?”

The short answer, which you know as a CDI geek, is that it doesn't.  These social circumstances, while subject to coding when documented, count for nothing within the DRG scheme.  The unmistakable message is that either they’re entirely discounted and negligible, they’re so ubiquitous that everyone’s care is complicated by it and therefore no one’s is, or they’re common enough that to give credit for them will costs real money.  But as a clinician, I can’t tell you how many patients have prolonged their own courses through their own non-compliance, or are difficult to discharge safely because they literally have nowhere to go.  Working with patients, there’s no question that these circumstances prompt additional evaluations, require more extensive treatment palms, prolong length of stay, and promote readmissions.  But while codes exist within ICD-10-CM for these circumstances, they count for nothing within the MS-DRG scheme.

I also realized I didn’t know how something becomes a CC or an MCC.  I figured somehow it worked through the Cooperating Parties (AHA, AHIMA, CDC, CMS), but I had no idea how.  Is there a nominating committee, and do the wines each year get revealed at an awards show?  (The nominees for Best CC Related to a Catheter are…can I have the envelope, please?)  Maybe it’s an illuminati kind of things, with a select few sacrificing a goat while intoning the definition of a Secondary Diagnosis?

Because I have no life (at least that week…the Dental Empress was in Tampa with her high school friends falling out of a sea kayak while the College Student sat in his room, emerging only to permit The Father to do Chauffeur Duty), I decided to find out.  An inquiry to Coding Clinic has been submitted and I eagerly await the reply.  But until I do, why not mull over some of those conditions we see that might be eligible to join these hallowed ranks.  So here’s my list of proposed CC’s, some real, some…well, real, but less likely to stick.

Non-compliance:  There is absolutely no question that medical non-compliance impacts patient care.  In some cases, non-compliance may actually be the principal driver of admission, if a condition that was otherwise well-controlled exacerbates because a patient was non-compliant with treatment or follow-up plans.  Non-compliance while in the hospital can also lead to the need for further interventions and care.  (An internship memory is of a 450 pound man who kept going into CHF no matter how many diuretics we threw at him the day before.  Turns out he was getting salt-loaded in the hospital with midnight family ruins to Taco Bell, and when he was at home he had no air conditioner so he kept drinking cold sodas to stay cool.  Discharge plan was no fast food and the hospital chipped in a hundred for a wall unit.  Kept him out all summer.  It was a simpler time.)

Granted, there are patients for whom non-compliance is not of their choosing.  People may simply not be able to afford their medications, have transport issues to and from appointments, or be able to take time off work for needed follow-up.  Perhaps patient education hasn’t been up to snuff, or educational deficits prevent honest understanding of the Plan of care.  Some prefer the newer term “non-adherence” to describe the behaviors of this group, because they can’t adhere to treatment through no fault of their own.  That makes some sense to me.

However, while it is absolutely not politically correct to say so and flies in the face of most of our extreme liberal concepts, it seems inescapable that often one chooses their fate.  I got close to fisticuffs in a small group discussion about the social determinants of heath. These are things like race, income, education, geography, etc, all of which can absolutely impact upon health and health care.  No argument there.  But when I noted that in my ER life, there were a subset of folks who every Friday, unbidden by cultural concerns or peer pressure, feel compelled to go to the bar and get their head whacked with a pool cue, that was considered anathema to the modus of the day.  And yet people make the same bad choices over and over. How many times have I been married again?

Homelessness:  If we spoke before about the social determinants of health, homelessness has to be near the top of the list.  Homelessness complicates care for all the reasons you might expect…inability to get medications, inability to attend follow-up…as well as preventing basic hygiene, all of which can result in increased needs during a hospital stay.  Homelessness can also delay discharge while Case Management seeks out someplace for the patient to go.  Clearly CC material.

Patient with Relative in Health Care:  If the worst words an ER doc can hear are “Remember that patient you saw last night,” the third worst are “My aunt is a nurse.”  (I’ll save the second worst for another time.) Nurses are good people, and they want to be helpful.  So when a relative calls they rattle off all the possible diagnoses, give them a list of all the tests that could possibly be performed, and then send them to the ER with all this in hand.

Once you see the patient and offer you thoughts based on years of training and experience, they hand you the cellphone and make you talk to the relative “who’s a nurse.”  (If you’re lucky, you get to stand in the room for fifteen minutes while they call another relative to look up the number.)  You have to talk to them before you order labs and xrays, discuss the results with them, and clear any plan, because the relative in the ER insists that you do.  Meanwhile, the “nurse” has usually called the patient’s own physician who’s been jolted from his sleep and demands to know exactly how and why you’re killing the patient.  If the case gets to the floor, repeat twice daily and toss in a few calls to the Respiratory Supervisor and Case Management to boot.  Of course, the patient will stay just a few days longer because the nurse has to approve of the discharge plan.  One forward-thinking hospital I know of uses measures of nursing intensity that account for the “difficult family.”  Ahead of the curve.

(Did I mention that most of the time the relative who’s a “nurse” is an aunt or cousin who’s actually a CNA in a nursing home?)

Interestingly, patients whose relatives are doctors are equally insistent on passing the phone to you, but the doctors themselves are usually much easier to deal with as they still don’t want to wake up at night, no matter who’s calling.  (As my father says, “Family practice doesn’t mean your family.”)  Attorney relatives are even more of a breeze, because somewhere in their cold little prune hearts they probably realize that if their second cousin is calling from the ED from 3 AM and already wants to sue, there’s probably some craziness there. 

Being form New York:  This similar to Nurse as a Relative in workload impact, but seems to be limited to Snowbirds and Tourists whose primary domicile in within Manhattan.  To put it delicately, New Yorkers are supremely confident that everyone else is a moron.  This includes physicians, which is why anytime a patient is from New York City I’m supposed to check with their own doctor, who is on staff at Columbia University or Mt. Sinai Medical Center or the like, before I do anything.  (This is one time that I thought having a Jewish last name might help, but my accent gives away that I’m not one of them.)

When this happens, there is a part of me that wants to tell them that the way you get on staff at an academic medical center is to do a residency there and be too scared to leave.  That the title “Clinical Associate Professor” means nothing but you’re in private practice and you let some medical students tag along.  That the problem with the Big East Medical Centers is, in the words of a Johns Hopkins Residency-Trained Specialist, ”They don’t understand that you can get good neurosurgery in East Pigsty, Rhode Island.”  But it’s not worth the time it takes to orient these Yankees back to reality.  So I dutifully call the doctors as requested, whom I think are trying to be as nice as a New York doctor can be while dealing with their inferiors.  The one redeeming feature of these calls is that doctors from Brooklyn, Queens, and The Bronx tend to swear a lot, so it’s fun to put their direct quotes in the medical record and see if there’s a code for the diagnosis of “low pain threshold wuss.”  (That’s the polite version.)

Of course, it’s not all diagnoses.  There are some procedures that should be CC’s as well.

Intubation for airway protection:  Patients are not always intubated for respiratory failure.  On many occasions, they’re intubated for airway protection.  The intoxicated patient or the patient with seizure or stroke may have an adequate respiratory drive, but altered levels of consciousness, diminished gag reflexes, or difficulties with swallowing raise the risk of aspiration and mandate that airway compromise be prevented.   While the patient who is intubated purely for airway protection may be an inpatient for the same amount of time as one that is not intubated…your alcohol burns off at a similar rate whether you’re “smoking plastic” or not…there is no question that the level of nursing care and monitoring required of an intubated patient exceeds that of a non-intubated peer.  This one should be a no-brainer.

Use of an Electronic Medical Record or Patient Satisfaction Surveys:  Find me the doctor, nurse, or other professional involved in patient care who says the EMR improves their workflow, speeds their day, enhances patient care, and simply makes their life better.  While you’re at it, send me the docs who think that Patient Satisfaction Surveys do the same.  Begin now.

I’m waiting.

Still waiting.

What if there were free cookies in it?

(Crickets.)

Enough said. 

Administration of Turkey Sandwich and Sprite:  This common clinical procedure contributes to measures of resource intensity through the need for staff to acquire the sandwich, apply required condiments, put ice in a cup, locate a straw, and cut off the crusts for those of tender gums.  Multiple applications are often required, and may be accompanied by the need for puddings and fruit cups.  Paradoxically, provision of such comestibles may actually enhance measures of Utilization Management, especially when used to drive early discharge in the Observation Setting.
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Hey, it’s Grammar Guy here.  I can live with the political correctness of “Medical Non-Adherence.”  However, I can’t reconcile with the term “Psychogenic Non-Epileptogenic Seizure.”   This is what we would usually call a pseudoseizure, but given a new label because psuedoseizure conveys the impression that patient is faking and maybe the poor dears just can’t help it.  It’s kind of like saying that when I was in my twenties and dating several girls at once I was having “Psychogenic Non-Intentional Cheating Behavior” instead of being a Hormonal Lying Cheating Dog.   The only saving grace about this term is after I explained it to a paramedic, he would take great delight in calling in on the radio about PNES seizures.  And yes, it’s pronounced exactly like you think. 


I'm Back! (Again.)

If you're a regular reader of this blog...and hey, who in the lower 48 states isn't...you'll know that the term "regular reader" is a misnomer, as you can't be a regular reader of an irregular publication.  (I suppose you could be irregularly irregular, which signifies atrial fibrillation and a need to listen closely to the list of side effects on the Eliquis commercial; or you could be regularly irregular, in which case Dulcolax may be your product of choice.)

The blog is irregular because of me.  I'll go through these phases where I'm determined to write, and then others where I'm more determined to sit and stare blankly at Facebook.  If you look at the dates between my blog postings, Facebook wins.  A lot.  But I've recently gone through the humbling experience of estate planning for my closer-than-I-would-like-to-think-it-might-be regression to entropy, and I think that even in my dotage (Kim Jong Un is not the only person who can use that word...I'm still working on cofevre) I might have something to say.  If nothing else, this blog and the "Keep Our Schools Healthy" Kansas school influenza cartoon are my stakes in eternity, and as Beowulf tells us that's really all you've got in the end:

"...the kindest to his men, the most courteous man, the best to his people, and most eager for fame."

(That sounds exactly like me.)

As some of you may know, last October I went full-time bureaucrat.  I'm the Physician Advisor for Clinical Documentation Improvement at Baptist Health, a five-hospital system in Jacksonville, Florida (I'm in JAX, of course, in my Forever Commune with the Dental Empress).  The job is pretty much trying to translate clinical terminology into the administrative language of medicine, and it's really quite fun.  One of the best parts is that I've been given the opportunity to write for the blog site of the Association of Clinical Documentation Improvement Specialists (ACDIS).  They've been great in allowing me pretty much free rein to write about whatever interests me, and my pieces show up regularly.  I have no idea if anyone reads them, but it's fun for me, and I've decided that my goal is to become the "Bad Boy" of Clinical Documentation.  I've never been a Bad Boy.  I'm very excited.

I share all this with you because the blog will, from time to time, begin to feature the original versions of pieces I've written for ACDIS.  As such, they may have some clinical documentation stuff in them that you may frankly find kind of boring.  (It's not an industry built on adrenaline.)  But I wanted to post the originals because by the time the ACDIS people get through with the professional edit, they sound like they come from an interesting, informed, and fundamentally sound human being.  You know, not me.  I also figured that since I had ten or so pieces already saved up, I could get a lot of material out on the blog quickly.  At one post a week, that gives me two and a half more months to play on Facebook.

The first of this genre was posted last May, after I attended my first ACDIS Conference and toured the exhibit hall, goody bag in hand.  I'll post the next one tonight as well, with more to follow.  Some are incredibly wonkish, some are just fun.  More of the real stuff on the way as well.  Thanks!

Tuesday, June 6, 2017

Salt of the Earth

“I think he’s dehydrated,” said the young woman, sitting in the industrial-strength plastic chair next to her boyfriend.

It was far too early one weekday morning, and the patient in question, the potential dehydratee, was sitting up on the cot eating Cheetos.  Fried, not puffy.  (Personal note:  All Cheetos should be puffy.  Both orange and white cheddar are acceptable flavors.)

“Okay, what’s been going on?” I said.

“He’s been throwing up all day.”

“Uh-huh,” agreed the object of her affections.  Thin, wiry, he spoke while exposing a thick tartar of Cheeto residue between his sparse remaining teeth.  “I’ve been throwing up all day.
“How many times have you thrown up today?”

“A lot.”

Last time I checked, “a lot” was not a number.  “How many is a lot?”

“Twenty.  Maybe forty. “
 
“You must be feeling better.  You’re eating a Cheeto.”

“Yeah, but just now.  Besides, I think the Cheetos are what make me throw up.” 

At a certain point in the conversation, you know you’re not going to win.  All that time you spent learning about effective techniques for patient education and empowering individuals to be responsible for their own health become just more hours in your life you’ll never get back.  Kind of like the first time you saw Avatar or the thirteenth time you saw Team America: World Police.

(Okay, I lied about that latter one.  Team America:  World Police is funny EVERY time.

Lisa:  “If you could promise me that you would never die, I would make love to you right now.”

Gary:  “I WILL NEVER DIE.”  And it’s all puppets.)

So instead of prolonging the conversation, I default into what is formally called my “Medical Screening Exam.”  For those not in the know, when a patient comes to the door a federal law called EMTALA directs that a ”qualified provider“ needs to perform a “medical screening exam” to determine the presence of an “emergency condition” in any patient who presents to the ER.  The active ingestion of Cheetos is enough to convince me, as a skilled and experienced observer, that there is no emergency medical condition present.  However, unless I acquire additional historical information and perform a physical exam, there is nothing I can really charge for. 

The Medical Billing Exam completed, I sit down on a rolling stool and prepare to deliver Canned Speech #12, the one where I say “I’m sorry you were throwing up at home, but everything looks good now.  I could get labs and x-rays, but I don’t think they’ll be helpful and I hate to stick you full of holes or blast you full of radiation if we don’t need to.  Whatever it was seems to have gone away, and the fact that you’re able to eat now is a good sign.  Rest, drink clear liquids…that’s something you can see through, not a Coke…yes, you can see through vodka but that’s not the same.  Anyway, please follow-up with your own doctor or come back and see us if you need to.”  (Sometimes I have to add on to the speech, like with Addendum 3A:  “I’m sorry, I can only write a work excuse for the time you were in the ER, not for the last three days you didn’t go to work, Addendum 4c:  “Yes, I know your aunt is a nurse, but…” or Addendum 2B:  Yes, I also know the CEO.”)

As I’m accessing the mental file, the young woman speaks up again, a bit of hesitation and worry in her voice.  “But I know he’s dehydrated.”

She seems nice, nervous, a little wet behind the ears, looking for reassurance.  I’ll give it another try.  “I understand your concern.  But he’s eating fine right now, his examination’s normal, and I think whatever it was has probably run its course and he’s gonna be fine.”

“But it was salty, and when you get dehydrated it gets salty.”

A pause.  If I could raise a single eyebrow, I would have been Spock-like.  
 
“What was salty?” 

There’s a brief moment of doubt, but I forge ahead because I can feel there’s a story here.  I just don’t know it yet, but I’m willing to incur the wrath of my Charge Nurse by prolonging my patient throughput times to find out.

She looked at me, then cast her eyes sheepishly to the ground.  He begins to smile, the Cheeto ooze tracing across his lips.

“Well, he wasn’t feeling good…”

His grin expands to span his orange-dusted face.

“And I thought maybe, as a special treat…to make him feel better…and it was almost Wednesday, and we do that once a week…”

The moment of revelation.  “And it was salty.”  I nod my head knowingly.

“Yes.”  She murmurs, then steels her gaze with a knowing look.  “And everybody says that you have a lot of salt in you when you get dehydrated.”

It’s kind of nice to know that in our age, when the internet arms every man with just enough knowledge to be their own doctor but not enough experience to know what any of it means, that the spirit of personal inquiry and those resulting “eureka moments” still prevail.  And when someone learns something new, we in medicine usually honor them accordingly:

Hail to thee, Discoverer of the Viking Test.  You know, the Vikings. From that high school in Topeka.  The one north of the river.  I think it’s called Seaman.

****************

Hypernatremia is a condition where the body’s sodium content is abnormally high.  Sodium is critical to the body in maintaining fluid balance.  When it rises, it’s usually not because someone has been feasting at the salt lick.  When someone is severely dehydrated and as water leaves the system, the concentration of sodium in the blood rises.  It’s pretty common in nursing homes, where the ill and infirm often can’t satisfy their own thirst. 


Last month a patient was sent in from the nursing home for hypernatremia with a sodium of over 170 (normal tops out at about 150).  Looking through his records, we found the usual potpourri of medication lists, Powers of Attorney, and an Out-of-Hospital Do Not Resuscitate Order (DNR) forms.  This prompted the following conversation at the nursing station:

“He’s pretty salty.  Like that place where you float.”

“You mean the Dead Sea?”

“Yeah, but he’s not dead yet.”

"Maybe we should just call it the DNR Sea.”
"Whatever floats your boat."

(Yes, this is a real conversation.  Do you doubt?  "Vas you dere, Charlie?")