A Call to Action on Hypertension Control

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Join me in taking control of hypertension across our nation. Together, we’ve got this.”

–Jerome M. Adams, Surgeon General of the United States

Control of hypertension has been shown to reduce heart attacks and strokes, reducing both morbidity and mortality.

On a population basis, blood pressure control in the US has worsened from 53.8% under control in 2014, to 43.7% under control in 2018 (JAMA, September 22/29, 2020). This has led the U.S. surgeon general to declare a Call to Action on Hypertension Control. The goal of the U.S. Department of Health and Human Service’s Million Hearts campaign is to have 80% of patients with hypertension under good control, defined as a blood pressure of under 140/90.

Unfortunately, COVID-19 is likely carrying us further away from this goal. Patients with telemedicine visits only have their blood pressure assessed only 9.6% of the time, compared to 69.7% of the time during office-based visits. (October 2, 2020 edition of JAMA Network Open Access)

About 25% of adult PHC members have a diagnosis of hypertension. From pharmacy data, 17% are taking at least one blood pressure (BP) medication. Their level of blood pressure control, in 2019, averaged around 65%, much better than the 43.7% rate found nationally by JAMA, but far below the 80% goal of the Million Hearts campaign. This 80% goal is achievable, as shown by six of our larger primary care providers whose hypertension control rates were better than 80% last year:

Fairchild Medical Center (Yreka, Siskiyou county):       89%

Northbay Center for Primary Care (Solano county):      84%

Kaiser Permanente, in Marin and Sonoma counties:    82%

Shasta Community Health Centers (Shasta county):    82%

Petaluma Health Centers (Sonoma county):                  82%

Sutter Lakeside (Lake county):                                       81%

Before the 1980s, diabetes self-management (including patient monitoring of their own blood sugar), was NOT the standard of care. Patients had their blood sugar measured in the laboratory or in the doctor’s office. Since the 1980s, it has become standard of care for all persons with diabetes to monitor their own blood sugars.

Blood pressure monitoring today is where blood sugar monitoring was in the 1970s. It is time to empower patients to monitor their own blood pressure at home. One of the strategies listed by the Surgeon General is to “Empower and equip patients to use self-measured blood pressure monitoring.” The Million Hearts campaign describes the evidence base showing better blood pressure control with home monitoring, combined with a medical team that uses this data to take action.

Partnership HealthPlan of California (PHC) covers home blood pressure monitors for our members. These can be obtained from a community pharmacy with a prescription/order from the Primary Care Physician (PCP), until December 31, when the state pharmacy carve out kicks in. Medi-Cal Rx will be administered through the Fee-For-Service (FFS) delivery system. For more information and to apply for your Practice ID number, visit their website. Additionally, we have a direct distribution pilot for BP monitors on a first-come, first-served basis. Interested providers will need to complete the DME Request Form on our website. This program will be continued and expanded in the year to come.

Petaluma Health Center had a best practice with us. Instead of reminding their clinicians to remember to prescribe BP monitors, they sent a text message to all their PHC patients with hypertension and asked them to respond if they wanted a home BP monitor. This was an effort to reduce the exposure to COVID-19, by reducing the trips into the office to check their blood pressure. About 10% of those texted responded with a request for a BP monitor. Petaluma Health Center set up a streamlined system to send the orders to PHC (through our direct distribution pilot), and we delivered the devices directly to the patients’ home.

We hope you will consider an active outreach campaign like this, for your patients with hypertension. As our Surgeon General says, “Together, we’ve got this!”

Informed Consent: Alternatives to “Weighing Risk and Benefits”

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Beware of words – they are dangerous things. They change color like the chameleon, and they return like a boomerang.”

–Dr. William Osler

The words we choose to use in our interactions with patients convey underlying meaning. Sometimes this underlying meaning can affect patient decision-making in unintentional ways.

In an editorial in the September 8, 2020 edition of JAMA, entitled “Improving Physician Communication About Treatment Decisions: Reconsideration of “Risks vs Benefits,” the authors argue that the commonly-used phrase “risks vs benefits” implies that harms from a procedure are possible, but the benefits are assured. This asymmetry would be corrected by using the phrase, “weighing the chance of harm and chance of benefit” of a particular intervention.

One physician responded to the editorial, noting that additionally, the “chance of harm if nothing is done” must also be accounted for, if a complete picture of the probabilities to be weighed is to be presented.

This may be the most accurate presentation of everything a patient must consider, but humans have difficulty understanding what the probability of an outcome really means. Experts in shared decision-making recommend using visual representations of probability, or comparing the probability to something more understandable, like the probability of a car accident while driving home.

Such devices may still be too hard to grasp for patients seeking certainty when making decisions. Such a desire for certainly is a big driver of vaccine hesitancy, in which the absence of certainty of safety of an intervention is used to default to not taking action.

Logically, a decision of whether to act or not should balance the chances of harm or benefit of the intervention, accounting for the chances of harm of no action. In reality human brains are generally wired to choose to not take action if they are not certain of what they want. Psychologists call this omission bias, the tendency to favor an act of omission (inaction) over one of commission (action).

Of course, this is just one of many biases, which come into play in the clinical interaction between clinician and patient that may impact the patient’s willingness to undergo an intervention.

Nonetheless, changing our language from “weighing risks vs benefits” to “considering the chance of harm and the chance of benefit of the intervention with the chance of harm of doing nothing” may help some patients weigh their options in making therapeutic decisions.

Managing to Optimize Quality: The Case of Southcentral Foundation

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“So you may be reading this and thinking,
‘Yes I do all of those things – there’s nothing to learn here.’
My challenge back to you is, really?”

-Karen Barnett, NHS (England), reflecting on the success factors of Alaska’s Southcentral Foundation

Southcentral Foundation, a tribal health center in Anchorage, Alaska, is recognized as one of the world’s leading models of health care redesign and is a recipient of the 2011 and 2017 Malcolm Baldrige National Quality Award, the only health center in the United States with this record. Their Nuka System of Care is based on a Native Alaskan value framework. “Nuka” is an Alaska Native word that means strong, giant structures and living things. It is also the name given to Southcentral Foundation’s whole health care system, which provides medical, dental, behavioral, traditional and health care support services to more than 65,000 Alaska Native and American Indian people.

In the Nuka System, strong relationships between primary care teams and patients (known as customer-owners) have helped manage chronic diseases, control health care costs, and improve the overall wellness of the people they serve. Recognizing that individuals are ultimately in control of their own lifestyle choices and health care decisions, Nuka focuses on understanding each customer-owner’s unique story, values and influencers in an effort to engage them in their care and support long-term behavior change.

Southcentral Foundation’s management theory can be broadly defined as “tight-loose-tight.”

“Tight” management means that there is considerable structure that is set by leadership that employees must adhere to. “Loose” management means that there is no rigid structure in place and employees have more flexibility to do as they see fit. Their approach to management employs both types.

There are two major things that are “tight” under this management style.

The first is the overall philosophy and the broad picture of how they approach health care. All care teams must follow the organizational philosophy and operational principles. They must practice relationship-based care and strive to understand the story of each customer-owner they serve. They must make use of communication techniques such as advocacy and inquiry to facilitate the formation of the strong relationships, which are at the core of the Nuka System of Care.

The other element of clinical care that is “tightly” managed is outcomes. Each care team has certain health outcomes, for the panel they care for, that they are responsible for reaching. These health outcomes are tracked and are compared to national benchmarks; care teams are able to view their panel’s status on these outcomes at any time. The team is accountable for reaching these outcomes and if they fail to do so, management will step in and determine how best to support them so they can.

Management of all other aspects of clinical care at Southcentral Foundation is “loose.” This means that the specifics of how the team operates, and how they organize their work day-to-day, is mostly up to the team itself. So long as they are following the philosophy of the Nuka System of Care, and achieving the outcomes they are accountable for, teams have considerable freedom in how they operate. They are free to innovate and experiment. Their management does track what teams are doing in these areas, but only so that practices that are working well can be spread further across the organization.

This “tight-loose-tight” philosophy of management has allowed their care teams a great degree of flexibility while maintaining the values of the Nuka System of Care, and supporting good health outcomes for customer-owners.

Southcentral Foundation shares its best practices on leadership, management, quality, and COVID-19 on its website, in publications and at conferences.

Staying Connected, Virtually

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“I define connection as the energy that exists between people when they feel seen, heard, and valued; when they can give and receive without judgment; and when they derive sustenance and strength from the relationship.”
–Brene Brown

The physical separation forced on us by COVID-19 has led us to better value the connections we have with each other. Video connections can help (compared to email and phone calls) but nothing beats the in-person sighting of a friend or family member, even while wearing a mask.

Not shaking hands or hugging can take a toll, though. Human touch between friends is associated with release of oxytocin, the hormone that stirs maternal and paternal bonding to children. In a sign of the times, blankets containing weighted glass beads that mimic the effect of a hug have seen increases in sales during the pandemic.

Seeing warm friendly smiles from co-workers and strangers is also a rare event.  Seeing a smile triggers the brain’s mirror neuron system, the physiologic foundation for empathy, a key component of successful clinical and professional interactions as well as a promoter of positive feelings.

For health care professionals, the increased use of virtual patient visits, and virtual meetings with colleagues, can impact our professional satisfaction and identity. There are many ways to mitigate this:

  1. Use video instead of telephone for interactions where possible
  2. Ensure video setups allow consistently good quality video and audio
  3. Adjust content to allow more back and forth communication
  4. Use expressive eye contact when interacting while wearing a mask or on a video call

 

Update of COVID Infection, Exposure, and Testing

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

You have probably read news stories of a problem with the state system for reporting and tracking COVID testing, and the slow turnaround time for COVID test results from many lab vendors.  When this is combined with the substantial increase in cases and deaths we were seeing before the state database issue, this means the local health departments are hobbled in any attempts to try to control the pandemic with contact tracing, isolation and quarantine.  This impacts essential businesses and will impact  counties in the PHC region that will have the option of opening schools.

This affects us in three ways:

  1. A change in advice on the role of testing when we, or those in our family “bubble,” have symptoms or are exposed to someone with symptoms.
  2. Instead of relying on county contact tracers, we all need to become knowledgeable in the essential advice contact tracers give, and work collectively to spread this information in our families and the communities we interact with.
  3. We all need to redouble our efforts to slow the spread of infection: diligently practice physical distancing (especially by limiting travel, large gatherings, and crowded settings), appropriate use of masks/facial coverings (covering nose and mouth when in a public setting, especially indoors or when continuous physical distancing is not possible), as well as hand hygiene.

Potential COVID-19 Symptoms and Potential COVID-19 Exposure: Updated recommendations

General Principles

The two reasons you may be at higher risk of COVID-19 transmission:

  1. You are infected with COVID-19 and have symptoms.
  2. You are infected with COVID-19 and have no symptoms (and probably don’t know you’re infected).

Isolation and quarantine are different:

  • Isolation is for either laboratory confirmed COVID-19 infections or for individuals with symptoms suspicious for COVID-19.  The time period for isolation is 10 days after the symptoms began or after the date of the test (if the person was asymptomatic), provided the patient has no fever for 24 hours while not taking a medication that would suppress fever AND any symptoms are substantially improved.  If a person is severely immunocompromised, the isolation period is extended to 24 days.  COVID test results do not change the isolation period.
  • Quarantine is for asymptomatic close contacts of confirmed or suspected COVID-19 infection or situations with high risk of transmission, such as gatherings of un-masked individuals or returning from travel to a high prevalence area.  The time period for quarantine is 14 days after the last day of exposure to the person or situation that put the person at risk.  If a person under quarantine develops symptoms, they become a suspected case and must begin a 10 day isolation period.  Due to the shortage of COVID testing, testing for all those in quarantine may or may not be possible.

If one person in a household bubble is isolated due to confirmed or suspected COVID-19 infection, the entire household would be subject to quarantine.  The isolated person must be separated from everyone in their household bubble who are now in quarantine, to reduce ongoing spread of infection from the isolated person and the quarantined people.  Exceptions may be made for parents with small children.

If some members of the house are quarantined, say because of a workplace exposure or recent attendance at gathering without masks, they must be separated from those in their household “bubble” that are not under quaratine, for the entire period of the quarantine, to prevent infecting them in the pre-symptomatic or asymptomatic phases of infection.

What does separation mean?  Briefly, sleeping in a room by themselves, staying in that room as much as possible throughout the day, wearing a mask when leaving the room, and avoiding shared bathrooms if possible.  For more details, see this summary from the Mendocino County Health Department.

Symptoms of COVID-19

If you develop any of these symptoms, you should stay at home for 10 days, and call your primary care provider.

CDC list of symptoms:
  1. Fever (temperature over 100 degrees F)
  2. New or different cough
  3. Shortness of breath
  4. Sore throat
  5. Loss of taste or smell
  6. Chills
  7. Muscle aches
  8. New headache that persists for more than a few hours or is different from your usual headache

Other common symptoms seen in COVID-19 infections:

  1. Fatigue
  2. New nasal congestion that persists for more than a day after treatment for allergies
  3. New rash
  4. Chest pain
  5. Nausea, vomiting, and diarrhea
  6. Stroke-like symptoms, such as confusion, slurred speech, weakness on one side of your body

Common Scenarios:

I had a stuffy nose all day and some allergy symptoms; must I isolate at home? 

Other illnesses can cause any of the symptoms listed above, but with the prevalence of COVID-19 being so high, it is best to assume that any of these symptoms could be COVID-19, even if you have other medical conditions that could explain them.  Doctors are sometimes giving inappropriate reassurances over the phone, without testing for COVID-19.

If you have one of these symptoms that persists, and you have been evaluated by your PCP and tested negative for COVID-19, and you normally would work within the office, you should reach out to your supervisor or the Human Resources Department in your organization to make sure it is OK to come into the office.

If I have one of these symptoms and it resolves, can I get a COVID test to see if I can come out of isolation?

You should stay home for at least 10 days after the symptom is resolved.  Given the shortage of tests some providers are not ordering tests on everyone with symptoms.  Given the high rate of false negative COVID test results, even a negative test should not be considered a pass to come out of isolation early if you had symptoms suspicious for COVID.  A positive test is helpful for reinforcing the importance of isolation and quarantine.

What Constitutes a Close Contact?

If you know you had recent close contact and possible exposure with someone you know has or recently tested positive for COVID-19, you could be infected.

A close contact to a confirmed or suspected case is defined as an individual who:

    1. Lives in or has stayed at the case’s residence, OR
    2. Is an intimate sexual partner of the case, OR
    3. Provides or provided care to the case without wearing a mask, gown, and gloves, OR
    4. Was within 6 feet of a case for a prolonged period of time (10 minutes or more).

AND

    E. This contact occurred while the case was determined to be infectious. A                 case is infectious within 48 hours before that person’s symptoms began                 and until that person is no longer required to be isolated.

Close contacts should follow the same precautions as those listed for someone who had to travel or attended a social gathering and is returning to work: a 14-day quarantine at home.

If you travel out of the area or if you break from universal precautions (by attending a party or wedding, for example, or even a smaller gathering outside your usual “bubble” or “pod” without wearing a mask), you should stay out of the office (ideally at home) for 14 days of quarantine after your transgression.

Preventing COVID-19 transmission when you don’t have symptoms

Universal Precautions: Take actions that assume you may be infected with COVID-19 and don’t know it, to prevent accidental spread in your community.

The best way to prevent COVID-19 transmission is to:

  1. Stay at home, away from face-to face social gatherings with people outside your bubble/pod,
  2. Wear a mask as directed by the state order
  3. Maintain physical distancing, and
  4. Wash or sanitize your hands.

If you do this well in your everyday life, this certainly minimizes (but does not eliminate) the risk of asymptomatic transmission.

As testing becomes more available, some of these recommendations will change; stay tuned.

Good Medical Decision-Making: Much More than Applying Evidence

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Medicine is best described not as a science, but as a form of flexible practical reasoning that often uses science.”

Adam Rodman, MD

How do the best clinicians apply their knowledge?

Last year, this monthly newsletter reviewed the propensity for mental shortcuts, biases and prior experiences that lead to poor medical decision-making, and discussed options for minimizing the degree that these cognitive traps affect our clinical decisions. Think of this as the cognitive psychology of medical decision-making.

When mental shortcuts are minimized, and reasoning is applied, we might, at first blush, think that the best reasoning limits itself to “Evidence Based Medicine” where high quality, prospective, placebo-controlled, double blind, allocation concealed studies are consistently applied in making medical decisions. In reality, several sources of knowledge (sometimes conflicting with each other) are brought to bear. The study of the nature of knowledge is also known as epistemology, a branch of philosophy. Within the medical realm, this is known as medical epistemology, a branch of the study of the philosophy of medicine.

In a grand rounds at Beth Israel Hospital in October, 2019, clinical professor Adam Rodman, MD defines a historical framework of medical epistemologies that clinicians use to decide on what treatments to offer patients:

  1. Observation – This involves obtaining a careful and complete history and physical examination, with review of lab work to categorize the disease or diseases that a patient has, and recalling how similar patients/disease categories that the clinician has directly observed or heard/read about have responded to treatments given. The earliest example of this is the 4,000-year-old Edwin Smith papyrus, in which an ancient Egyptian healer carefully described a series of 48 surgical cases and their treatments.
  2. Theory – Pre-scientific theories, such as ancient Greek humoral theory of disease dominated medical practice until the mid-nineteenth century, when they were replaced by scientific theoretical frameworks, such as physiology, immunology, biochemistry. These frameworks are then used to interpret observations (such as a rising creatinine in a patient receiving a diuretic), and make judgements based on this understanding.
  3. Experimentation/Clinical Trials – While there are scattered examples of medical experimentation before 1900, it was not very commonly used. It is primarily a twentieth-century framework, and led to the Evidence-Based Medicine movement, starting in the late 1980s. It includes applying a hierarchy of different types of medical trials and studies, with expert opinion at the bottom of the pyramid and meta-analysis reviews at the top. This pillar of understanding has crumbled to be replaced with the current standard: grading of available evidence, which takes many other factors into account.
  4. “Population Medicine”/Epidemiology/Biostatistics – This began in the early 1800s, in Paris and was first called the “Numerical Method.” This involves collecting data on numbers of patients and analyzing this data statistically for insights that can then be used to improve clinical decision making for the individual patient being cared for. The most modern applications of this are decision rules (for example for osteoporosis screening or genetic testing), “big data” analyses, and augmented intelligence medical applications.

Rodman contends that whenever clinicians make treatment decisions on individual patients, we use some or all of these frameworks, even on the same patient, in the same day. The frameworks often might lead to conflicting treatment options which need to be sorted out rationally. Importantly, the third framework is the preferred framework for Evidence-Based-Medicine purists, but real-life excellent clinicians seamlessly integrate EBM with the other 3 frameworks. We need not feel guilty or inferior when we use these other frameworks; they have a vital role in the decision making of all excellent clinicians.

In the end, to the extent medicine uses science, it is in the application of science to deciding on individualized treatment of patients that matters.

The medical ethicist Jose Alberto Mainetti stated it best in his research, Embodiment, Pathology, and Diagnosis: “Diagnosis is not knowledge for knowledge’s sake. It is knowledge for the sake of action. Medicine exists to cure, to care, to intervene, or in limiting cases to know when not to intervene. Medicine is not a contemplative science.”

Knowing the noble history of these four epistemologies can help us balance their use thoughtfully, both in our continuing educational activities to better master them and in applying them to make therapeutic decisions that best serve our patients.

Brief COVID-19 Updates

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“When we have nations, institutions and advocates working on this collective response, we do see remarkable impact.”
     -Bill Gates at the 2020 COVID-19 Conference

There are several timely updates that we know would be of interest to primary care clinicians. Please forward on to your staff.

Surge of Cases Nation-wide Leads to Testing Delays
Public testing sites sponsored by the State in several counties have found long delays in results for the lowest risk groups, as the state announced criteria for prioritizing testing. OptumServe and Verily sites sponsored by the counties are affected. County health lab and local hospital lab turnaround (including Kaiser) is faster, but capacity is limited. Home testing is being rolled out by Lab Corps and soon Quest will join them. We will include more information on this in the next update.

Although point of care RNA testing (Abbott and others) is less sensitive than PCR-based testing, but some public health experts feel that a less sensitive point of care test that turns around results quickly, is better on a population level for screening than a more accurate PCR test with results available in 10-14 days.

All COVID tests are covered by PHC when done by any lab provider with a Medi-Cal provider number, up to 2 tests per day, for both diagnosis and screening.

Remdesivir Shortage Leads to Narrower Treatment Criteria
On a call with one of our local health officers, we understand that Remdesivir treatment is now being delivered to those who are inpatient requiring low-flow supplemental oxygen, as these patients have the most likely benefit for the treatment. Patients not requiring oxygen and those on high flow oxygen or intubated are less likely to benefit and are not being prioritized. A five-day treatment regimen has become standard for most patients.

Eye Protection Recommended in Health Care Settings with Moderate Community Transmission
The CDC recommends that eye protection be worn in health care settings where patients with unknown or positive COVID status are being cared for. The eye protection should not have gaps between the skin and should not rest on the protective covering around the face, meaning eyeglasses are not sufficient (see CDC recommendation for details). We understand that CDPH is considering making this recommendation into a requirement in California.

Familial Autosomal Recessive Mutations Associated with Higher Risk of Severe Disease in Younger Patients
In a study that gives insight into the pathogenesis of COVID-19, a case series of 4 young male patients with severe COVID-19, were found to have a previously undiagnosed immune deficiency: a relatively rare putative loss-of-function variants of X-chromosomal TLR7 were identified that were associated with impaired type I and II interferon responses.

Obesity an Independent Risk factor for Severe COVID-19
A report from the American College of Physicians noted that Obesity is associated with an increased risk for intubation and death in COVID-19 patients under age 65, but not for those over age 65.

“Broken Heart Syndrome” Increased During COVID-19
An observational analysis of patients without COVID-19, receiving echocardiograms at the Cleveland Clinic, found an increased percentage with stress cardiomyopathy (also known as takotsubo syndrome or broken heart syndrome). The rate ratio before COVID-19 was 1.5 to 1.8%, while the rate ratio during the lockdown rose to 4.6%.

Stress cardiomyopathy is a physical manifestation of sustained psychological stress. This study shows the degree of population stress that the response to the pandemic is having on the community.

Childhood Immunization Rate Rebounding (Somewhat)
The graphic below, from the California Immunization Registry, shows that the rate of immunization for MMR (a proxy for overall childhood immunization activity in young children) has mostly rebounded in California in the past month. Overall, though, there is a remaining backlog. Without in-person school in many parts of the state, the usual August bump in immunization rates may not occur this year. Next week, PHC will be starting a state-mandated phone outreach campaign to children under age 2 to remind them of the importance of vaccination and well-child visits.

De-identified Humorous Examples of Actual Medical Records

By Jeff Ribordy, MD, MPH, FAAP, Regional Medical Director

Back in 2018 we published a mildly humorous blog post highlighting medical bloopers that we have encountered as we peruse the chart notes we receive. Of course back then, EHRs were so new that most providers were still getting used to working with them. Nowadays, everyone is such an expert we rarely see charting mistakes…..

Just kidding!

Here is our long awaited sequel with upgraded oopsies – just like the EHRs we all use.

As we share these I want to mention as in the previous post – this is not to point fingers but with the understanding we all have made similar mistakes.

From the “Not Sure That’s How That Works” Department

–…he sleeps flat with 8 pillows <…>

–She lifts boxes which way 5200 pounds all day long while working in a warehouse.

–General: Pt is awake, alert and oriented. No acute distress. Husband present. PT is ambulating in a wheelchair.

–Born as full term at 51 weeks, no major complication reported during delivery.

–Allergies: CARBOHYDRATE

–He was twin B (5 lb 11) needed chest compression for 3 days. Not intubated.

–Is a 56-year-old male – Alcohol: Currently does not drink; but did drink a sixpack of beer per day for 78 years.

–Sister states that patient carries a diagnosis of schizophrenia but patient refused to take medication. Main symptoms of her schizophrenia was shyness and not talking to others.

–Patient states she believes she has MS. She states she did some online research and wants to be tested for MS. When asked what sx she is currently having in regards to MS, Pt asked, “Can I have a phone to look up the symptoms of MS.”

–Ms. M… had a sudden loss of both eyes that occurred in December 2018.

Might Need Another Treatment Plan…

–If the injection helps, then consider radio frequency abrasion.

–He was diluted with x-rays and sent home.

–Prognosis for controlling incontinence: Hyperlipidemia

–Discussed – Unfortunately kidney has failed to have any benefit from an L4 transforaminal epidural steroid injection.

–PLAN – Hyperlipidemia, unspecified, TraMADol HCI 50 MG tablet, 1 every 4-6 hours as needed, 30 days, 0 refills.

–Methamphetamine abuse  F15.10 – The patient appears interested in taking this habit.

Kid’s Doctors Say the Darnedest Things…

–3yo daughter Callie, works as a cashier

–SOCIAL HISTORY: The patient is in the fourth grade, denies use of alcohol and tobacco.

–10 year old female here with a chief complaint of eating.

–Please let mom know Xray from last week shows moderate poop.

Captain, the Universal Translator is malfunctioning…

–Ongoing tobacco use: Advised to quit yet another gallops left left knee surgery on their printer milligrams daily.

–Reminder of value of glucose level w/level of pain & why.

–Plan: Patient with hypoplastic left heart status post Norwood procedure N salmonella shunt mother with excellent Binder for following medical home we’ll need to clarify dosages of medications.

From The MD who was an undergrad Philosophy Major…

–The symptoms occur.

And more good advice for everyone:

–She married a drug dealer which she advises not to ever marry a drug dealer.

 

 

 

 

Poor Documentation Not Solved By Electronic Health Records

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“If it wasn’t documented, it didn’t happen.”
     -Aphorism passed on to all health care providers in their training

One of the promises of Electronic Health Records was that it would make medical information more legible, and complete.

While computer text is undoubtedly more legible than most handwritten clinical notes, it does not solve the issue of incompleteness, and may make it worse. A long progress note can be created using templates and short-cuts, but sometimes a clinician fails to record the core information of the history of present illness and the part of the physical exam relevant to that complaint. When this happens, anyone reviewing the record would come to the conclusion that the quality of care in that visit was poor and unacceptable.

For example, a patient comes to the office complaining of back pain. The progress note includes a depression/anxiety screen, smoking history, alcohol history, review of current medications, and the medical assistant’s note of the chief complaint of back pain, for the past week since moving a heavy couch. The clinician documents no further history, and the physical exam notes that the heart sounds are normal, the lungs are clear and the patient is in no acute distress. There is no recorded back or neurological exam. The assessment is back pain, and an MRI is ordered.

This electronic medical record generated note not only gives the Partnership HealthPlan of California (PHC) medical directors no details by which to judge the medical necessity of the MRI request, it reflects either poor quality care by the clinician, or poor documentation by the clinician, and possibly both.

The consequence of this: a denial of the MRI request, the need for a repeat visit to do the relevant history and physical exam, and a delay in getting appropriate care for the member.

This issue is definitely not universal. In the process of conducting utilization management reviews and investigations of potential quality of care issues, we also encounter very complete and appropriate documentation that reflects a logical collection of historical information, a thoughtful physical exam and a delineation of the differential diagnosis considered.

Sadly, we encounter many progress notes that incompletely address the reason for the patient’s visit. When we bring this to the attention to the Medical Director of the organization, they are often unaware of the issue. This is perhaps even more concerning, that health care organizations don’t closely monitor the quality of medical records and clinical decision making.

One of the best resources to offer a clinician with poor documentation practices is the UC San Diego PACE Medical Record Keeping course. Having your clinicians periodically audit each other’s charts is another way to promote attentiveness to the quality of medical recordkeeping and clinical decision making. Having a standard set of review criteria is important; Family Practice Management has an article on this topic.

Physician Assistants are required by the Medical Board to have a percentage of charts reviewed by their supervising clinician, a good opportunity to identify poor documentation practices. Although physician review of a sample of Nurse Practitioner Charts is not required by the State of California, it is also a best practice to do this on at least an annual basis, as part of a yearly performance evaluation.

One final note: excellent documentation practices help prevent medical liability lawsuits and licensure actions by California Medical Board/Nursing Board. It is better to have a system to improve documentation and decision making before such actions force the issue.

For a collection of de-identified humorous examples of actual medical records PHC has reviewed, see Dr. Jeff Ribordy’s blog.

Reinstating Patients Who Have Been Discharged

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Redemption comes to those who wait.  Forgiveness is the key.”

Tom Petty’s 1999 ballad Lonesome Sundown (part of Echo, his tenth album with The Heartbreakers) was written after completing inpatient rehabilitation, recovering from a 3-year period of heroin use. The line about redemption and forgiveness is a reflection of his need to be forgiven so he could again create new songs and genuinely share his art.

Some Partnership HealthPlan of California (PHC) members have experienced hard periods in their lives when their actions cause distress to those around them. In the health care setting, this may lead them to repeatedly missing medical appointments or have verbal outbursts with medical office staff. Sometimes, their behavior leads to disenrollment from a practice.

These patients may sometimes turn their lives around, and be ready to re-engage productively in relationships with medical providers and offices. They are often ready to seek redemption and forgiveness from the medical office that disenrolled them.
At the June PHC Physician Advisory Committee meeting, several physicians related how their practices handle these situations. Here are some highlights:

  • Patients should write a letter (potentially with assistance from an advocate), requesting re-enrollment, acknowledging the reasons for their disenrollment, explaining how their life has changed and expressing a commitment to act differently.
  • The office/health center should have a process for reviewing such requests, ideally involving both clinical and administrative leaders.
  • Many practices require the patient to wait for at least a full year after the disenrollment to consider a request for reinstatement.
  • If the request is denied, the former patient is given a written response, indicating if and when they may apply again for reinstatement.
  • If the request is accepted, the patient has an orientation session outlining expectations of behavior, up-front. For PHC members, PHC needs to be notified, as well.

Tragically, Tom Petty ultimately died of an opioid-benzodiazepine overdose in October 2017, related to his attempts to treat severe pain from hip osteoarthritis, for which he was hesitant to have surgery. In the 18 years between his recovery from heroin addiction and his death, he produced 8 albums and 2 film documentaries—a pretty good redemption.

If your office doesn’t have a process for considering re-enrollment requests, please consider developing one to allow former patients who have turned their lives around to have a second (or third, or fourth) chance.