Things That Make Me Crazy

I sometimes think I live in a tight little fantasy bubble where I want life to make sense and be fair.  I want it to be an uncomplicated place where, when resources are limited, we assess the problems and direct the dollars to things we know will efficiently fix the problems.  I'd like us to use our public health  dollars to feed hungry people, to house those without some place warm to stay, to help those in need learn strategies and get jobs so they can help themselves, and to provide health care to those who are ill.  In cases where there are big-picture items that lead to devastating consequences and enormous costs to society, I'd like us to target the causes with early interventions that are known to be effective: so measures to prevent drug/alcohol/tobacco abuse, better and more available drug treatments, and more resources dedicated to early education so that everyone gets the skills they need to earn a living and grow up to be a taxpayer.  

Instead, through some mix of politics and medicine, there are these untested (or poorly tested) ideas out there that cost billions of dollars and money gets diverted away from being used for the direct good of the people.  Maybe I'm wrong-- I'm sure there are plenty of people who disagree with me and think that these changes are important and will make the world a better place -- so by all means, feel free to comment. tell me why I'm wrong, or do add to my list.  It's a little of 'one guy unsuccessfully tried to blow up a plane with his sneakers so millions take off their shoes for screening every day.'  The cost is phenomenal, but I do have to  admit that no planes have been blown up with shoe bombs since, and if my child was on a plane that didn't explode, then the cost to society was worth it, but it's not a very "public health" way of thinking.  But you have to wonder what we're giving up when we put a lot of time, money, or resources towards low-probability events or towards paperwork for the sake of paperwork.  In no particular order:

Dinah's List of Aggravating Diversions from Productivity in 2013

• CPT codes that force psychiatrists to differentiate "medical care" from psychotherapy with rate changes depending on whether the psychotherapy component takes 52 minutes or 53 minutes or the session, and creates 15 different options for coding a single psychotherapy session.
• 68,000 ICD-10 codes for the purpose of diagnosis/billing. Really?  ClinkShrink will be thrilled, code Y92146 is for getting hurt at a prison swimming pool.  Prisons have swimming pools?  And Y92253 is for being hurt at the opera, so Clink and Jesse can both rest assured that injuries they may incur can be coded. This helps us how?  And, no, US prisons don't have swimming pools, but why should that stop us from having codes?
  
• Legislation -- complete with the cost of databanks, means for reporting to such databanks, and the cost of enforcement -- to keep the poorly-defined 'mentally ill' from owning guns when there is no such effort to keep the family members or roommates of those people from owning guns, and there is no such effort to keep guns from those who are known to be dangerous if they are not mentally ill.  The laws in Maryland also include 'habitual drunkards,' -- but there is no provision to report those who goes to detox/rehab or have a second DWI/DUI from having a gun. 
• Continued support of the Second Amendment as interpreted rather widely, despite 40,000 gun deaths/ year, some of them innocent small children. "A well regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed."  I'm just not sure that the founding fathers foresaw a society of drug addiction, rampant suicide, and a country with a firearms death rate beyond any other country in the world.  There was slavery when the second amendment was written, and I don't think the amendment included slaves, so clearly the 'right of the people' did not mean all people, or include assault weapons that did not yet exist.  The second amendment has become an impenetrable devotion -- in Maryland's it's some state legislator's main forum -- as if it were a religious belief.  And people with mental illnesses have taken the blame for all inappropriate uses of guns.  See yesterdays Bloomberg Report for our President's pronouncement, and by all means, read the comments.   
•  Meaningful use -- a government/Medicare phenomena that creates a tremendous amount of work for physicians that does not seem to directly improve patient care (correct me if I'm wrong), and if it does, it doesn't improve patient care/outcomes in a way that warrants the time, and expense.  I don't really know what Meaningful Use is (such details never stop me from ranting), but I know the government will give me money if I'll convert to electronic records and use it in a particular way.  Otherwise, for every Medicare  patient I see, I must charge a lower fee if I don't use e-prescribing (which is not conclusively shown to improve patient outcomes) a certain percentage of the time, and that in 2013, to prevent an drop in my fees, I needed to put a PQRS code on one patient's insurance claim form.  I could not figure out what that meant, so I asked an APA assembly member who runs a hospital.  After two  separate half-hour phone conversations, one in-person meeting, and I have no idea how many hours of his time, he provided me a list of options which included things like "medications not reconciled, reason not given."  I opted to list on one patient's claim a code indicating he was not a tobacco user, and I'm told this was good enough to keep my fees from dropping 1.5% next year.  What's meaningful about this?
• CRISP/Government portals of patient records collected without patient knowledge/permission.  These may be very helpful for emergency care in crisis situation,  and perhaps they allow for data/outcome collection that will be used for outcomes research, but they cost a lot of money and after the NSA scandal, are we all comfortable with the government keeping our health records without our expressed permission?  Are we sure our health information won't bounce back at us in unwanted ways?
• Hospitals that spend HUNDREDS OF MILLIONS OF DOLLARS to replace existing, function, Electronic Medical Records when there are people sleeping on cardboard boxes outside their doors, and when such medical records increase the amount of time clinicians spend with computers and decrease the amount of time they spend with patients -- and don't necessarily decrease medical errors.  This feels wrong to me  on so many levels: there are shortages of physicians and we're diverting their attention to clicking through screens and checking off boxes that have nothing to do with the care of that particular patient, adding hours a day to physician workload, promoting physician burnout, and diverting funds to this project that could be used to pay for health care for human beings.
• Government-run health insurance exchange(ACA) websites that are basically unusuable and create too much frustration for the average person --especially the average person with medical or psychiatric issues-- to work efficiently.  One of my patients was blocked from signing up because he forgot his password, and the recovery question involved his pet's name, only he's never had a pet and was locked out of the system. 
• Hospital medical records that afford no privacy because thousands of people have access to them and patients can not opt out, other than to get care at another institution.  But if you want information about a patient from another institution, with the patient's permission, barriers are put in place to make this next to impossible.  I recently requested records from a local hospital ten minutes from my office, and two weeks later they sent me a form saying that the authorization my patient signed was not good enough, it had to be signed on their specific form.  How crazy is this?  Perhaps it's because that hospital's administrator was so busy looking up my PQRS codes that he wasn't updating their information release policies.
• That my state is proposing to spend money on programs to increase cultural awareness and competency on number of measures when people need food/housing/healthcare/job training.  I'm all for treating people respectfully, but maybe it would be cheaper to fire those who are demeaning to others rather than to set up training programs to make them 'culturally aware.' (Please forgive my cynicism, in a world where everyone is fed, housed, has healthcare, heat, education and jobs, I'm all in favor of programs to increase sensitivity to cultural issues).
• "That my state is proposing to add Assisted Outpatient Treatment (read: forced care) when we don't have enough information to know if this really works without other services in place.  We don't have  enough resources to care for people who want care, and this will entail forcing people to take medications that are known to have detrimental cardiovascular effects in some people,  distressing side effects in others, and may include forcing care on people when that care does not decrease their symptoms. If I thought the legislation was truly about getting care for the very sickest of people -- those 'dying in the streets with their rights on' -- I would be in favor, but I believe it's a "do something" measure to address spree shooters and has been tied to federal funding. 

Thank you for letting me rant.  That's what this was, and I appreciate it.  I feel much better now. 

Privacy please....

Over on Clinical Psychiatry News, I have a an article up on medical privacy, HIPAA, electronic medical records, routine dental care, compliance and regulation, and yes, fish.  Surf on over if you get a chance.

Podcast #67 : Things Get Flighty.

Podcasting got off to a slow start today.  We haven't done this in a while, and ClinkShrink recently upgraded her computer to Lion and it was not compatible with our MultiMix8FireWire mixer.  It was a long time trying, when Clink realized she'd downloaded a new driver without plugging the mixer into her computer.  She started the process over, and once it actually worked, there was the distraction that Clink and Roy both kept noticing birds at the bird feeder on the deck and Clink would have to stop what she was doing to take photos with a lens that doubles as a full-sized baseball bat.  The photo above is one of Clink's visiting birds.

Now there is some issue with a hat, and who knows what Roy is doing in the kitchen, but we're only two hours behind schedule, and I was late, so what can I say.   

Today's topics include:

Roy spoke with folks at the American Association of Technology in Psychiatry about how Electronic Health Records have not lived up to their promises.  In Michigan, there's a law that makes it a felony for a medical professional to put wrong information in, yet "the software requires you to commit a felony."  Here's a link to the Michigan law.

Roy talked about an Australian hospital where someone got in trouble for falsifying wait times in the electronic health record.

We talk about Rob's blog post: A Funny Thing Happened on the Way to Meaningful Use while we're rambling about electronic medical records.


Dinah mentioned the little bit of research she'd done on e-prescribing.  


We talked about Dinah's novels, past and future, including Monday at the Charm and her soon-to-be released novels on Amazon.  Home Inspection will be available as an e-novel on Kindle, momentarily.  No link quite yet.

We gave a list of our upcoming public talks-- these are in our sidebar.

And finally, we talked about the New York Times Magazine article called When My Crazy Father Actually Lost His Mind by Janeen Interlandi.

The winner of our podcast contest, mentioned at the end of our Jan 7 podcast, was "rossflem".   And now I know what the hat was for-- Roy was pulling a name from it! We'll be sending Ross a signed hardback copy of our book, "Shrink Rap: Three Psychiatrists Explain Their Work." 

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post.

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

Over on Clinical Psychiatry News....

Check out our CPN site where Roy is talking about Stage 2 Meaningful Use, and I've put down my final words (I hope!) on strip searching psych patients.  Do Check It Out if you'd like to see what we have to say, and to all those who helped me with this article, please accept my gratitude!  Roy and I would both love your feedback.


Lately, I feel like a moving obsession...I was preoccupied with medical marijuana legislation for a bit, then with how body searches are conducted of our patients, at the moment I'm reading Kaitlin Bell Barnett's new book Dosed: The Medication Generation Grows Up....my review is forthcoming.  What next?

EHRs & Privacy: Am I The Only One Who Cares About This Stuff?

 

Electronic Health Records are a wonderful thing.  They allow for the easy access of information from one doc to another.  Now when the patient takes the white pill for that bump, I can go in to the records and see what the bump was and what the white pill is.  Once in a great while, it has meaning for their psychiatric care, and it's good for general curiosity, too, and periodically, I may help with the education process if it seems important that the patient should have a greater understanding of their bumps.  Roy likes EHRs and President Obama will pay you tens of thousands of dollars to implement one in just the right way (too many hoops for me).  As a doctor, it's mostly nice.  I still see a lot of people who get portions of their health care in another system and I can't access their labs-- labs I actually need to have to safely monitor how their bodies are tolerating their psych meds, but I'm doing my best.  When I run labs on a patient who gets their primary care outside of our system, I hand them a copy to give to their doctor, hoping that I will spare them a needle stick and spare the 'system' (usually Uncle Sam) the cost of repeating the same blood work.  Who knows if that ever happens.


I've mentioned before that my gripe with this system is that any healthcare professional in the system can access information.  Now everyone I work with, and approximately 10% of my neighbors (wild guess here), and even some of my patients,  have access to this system.  The only thing that stops someone from looking up a friend's medical history is the knowledge that you will get in trouble-- and likely fired-- if you get caught.  But you have to get caught, which means that someone has to look up who accessed the information and track down if it was a legitimate accessing of information.  Now they do it, and people have been fired, and the prohibition is real, but we don't think that in a system of many thousands of people, there isn't a sociopath here or there?


Let me give you an theoretical example: what if a young nurse (he has access) starts dating a pretty young hospital worker (she does not have access to the records; also these people can be old and/or ugly if you'd like....just enjoying my fiction here).  He's curious about her; in fact, he's prone to a bit of pathological jealousy.  He decides to take his chances and look up her records and he notices that someone has run an HIV test on her (it was negative) and she's had a miscarriage a couple of years ago, one she never mentioned to him.  Oh, and psych records aren't in the system (yet, coming soon) but her primary care doc mentioned that she's on Prozac for depression and Seroquel for sleep.  Isn't Seroquel the big guns, maybe she's crazy.  So if he tells her he looked at her records, and she wants to report him, he's toast. But maybe she doesn't want to get him fired, so she eats it.  Also, once he's fired, he's just fired, not dead.  He can then tell whoever he likes, I suppose, especially if he loses his license.  And the saying goes that there are random "flags" that go up to catch wrong-doers, but this is a big system, so I am skeptical.


I've mentioned my concern about this to a few people, especially since the system is about to be overhauled.  I've suggested that each patient have a card or an identifier that the provider should get from the patient to authorize access to the information.  I've asked that this be brought up at planning meetings.  I get looks like I'm from Mars.  Obviously, all health care providers should have access to their patient's records, and in this system, there is no absolute guarantee that your neighbor won't be curious and you don't have the right to not tell the dermatologist that you had a vasectomy three years ago, or to keep your internist from making a note that your antibiotic was started in jail.  Okay, I will say that all of the records I've read (it's been years, that's a lot) are very professional, but still, sometimes the facts are the facts and they aren't all that savory.  I asked if the topic came up at the planning meeting and was told no one else was concerned.  My boss has agreed with me that I watch too much 24.


So I went to schedule a routine screening exam the other day.  I have no reason to be concerned about this, but I am generally uneasy about being in the massive data bank that is the system's records and I avoid it.  I called for the appointment, and the office had been taken over by my hospital system, something new!  I asked if my results would go into the main hospital computer.  Of course they will!  Thank you, I said, I will get my test elsewhere, and I hung up. 


Why doesn't anyone else care about this stuff?

Podcast 65: Copyrighting the Brain

Roy wants to remind APA members to VOTE! in the APA elections.


Roy talks about our Top 25 Posts for 2011.


ClinkShrink talks about copyright issues with the Mini-Mental Status Exam (MMSE).  We talk about what the MMSE is, what it measures, and why some folks are bothered by the copyright issues. Roy mentions an alternative, the MoCa, which may be used clinically without any permission needed.


Roy mentions his Clinical Psychiatry News article in the Shrink Rap News column discussing the October SAMSHA meeting on electronic health records in behavioral health.  He talks about continuity of care documents (CCD) and XML (Clink and Roy have now lost me in Geek Speak), which gives the outline about what was important about that 'episode of care,' or doctor's appointment, and the 17 categories of things that are documented.  This was a stakeholder meeting to come to a consensus about which behavioral health elements should be included in the CCD.  Roy talks about something called Granular Consent.
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This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. 

Thank you for listening.

Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post.

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

Ducking Around

Ooooh, let me tell you: I love vacation.  I really love vacation.  I'm back.  It's cold here, and I spent the day unpacking and doing laundry, and getting ready to start my week.  I returned calls, went in to the office and checked my mail, emailed, postal mailed, and watched the Ducks win the Rose Bowl.  Sad, because even though we Shrink Rappers like ducks, I have my own personal Badger out in Pasadena cheering for Wisconsin, and it's a sad football day for him, I'm sure. 


Roy did a great job of holding down the blog.  Please give him a hand.  Clink was off on another one of her adventures.  For some reason, vacation is not fun for her if there isn't the possibility that she'll fall thousands of feet, get eaten by some form of wildlife, or have her life depend on properly functioning equipment while she gurgles beneath the sea.  She's the only person I know where "I had a fantastic time" is followed by an injury report.


Roy's Happy New Year duck was taken from the Havre de Grace annual New Year's Duck Drop.  From the Aegis:

It was a glorious night for ringing in a new year. Temperatures, unusually inviting for a New Year's Eve in Harford County, hovered around 43. Wind was non-existent. And many people had gathered around the Havre de Grace Middle School grounds for the annual Duck Drop and fireworks to welcome another new year.

In other stories around the web, if you're a distracted duck, you might have notice that it's hard to find Ritalin or Adderall-- perhaps another example of DEA limits allowing Big Pharma to be being overly ducky about reducing supply of the cheaper, generic medications.  From the The New York Times, do check out "A.D.H.D. Drug Shortage Has Patients Scrambling."  


And if you're a duck contemplating filing for Social Security Disability, do read Dr. Steve's post on Thought Broadcast about The Curious Psychology of "Disability."  With 41 comments on that post, I'm going to swim away from the temptation to comment myself. 

And finally, for those ducks who want to know the latest on Electronic Medical Records, check out Shrink Rap News over on CPN for "Notes from SAMHSA's EHR Summit."  If that doesn't make you want to be served up with orange sauce, then nothing will.

So I love vacation, but I did miss all the Shrink Rappin.'  Happy New Year to everyone!  

From Clink: I don't have a duck in this race, so I thought folks might enjoy a seahorse instead. He's black with white stripes and seems to be perched on top of the green moray eel's head. Yes, the eel was that close.

No significant injuries this time.  A slight jellyfish sting and lots of no-see-'ums, that's it.

Not in My Record!

For a while now we've been talking about issues related to psychiatry and electronic medical records.  Roy is very interested in the evolution of EHR's.  


I don't like them.  I think they have too many problems still, both in terms of issues of efficiency and time, and how they divert the physician's attention away from the patient, and they focus medical appointments on the collection of data-- data that is used in a checkbox form: patient is not suicidal and I asked, whether it was clinically relevant or not-- and will therefore serve as protection in a lawsuit, or demographic information used by insurers, the government, who knows.

From a privacy standpoint, I think they are appalling.   If you are a patient in the hospital where I work, you get no say, your info goes in to the electronic record and everyone who treats you can access it.  And anyone else who uses the medical record in the hospital can access it as well; the "check" on the system, since much of our city is treated at this hospital, is the after-the-fact threat/fear of being fired or disciplined for looking at someone's record you shouldn't.  I believe the check should be before the fact-- that a patient should have a code, or PIN number they punch into the system that unlocks the system for that particular healthcare provider.  Or something akin to that.  


But what about the fears that people express on our comments that they will be judged and dismissed if their doctors know they've seen a psychiatrist or taken a psychotropic or been hospitalized?  On one hand, there is the idea that this information is more sensitive and should be protected, so that psychiatry records have traditionally been kept out of EHRs.  On the other hand, there is the belief that calling them "sensitive" further stigmatizes psychiatric disorders and it's time to treat them like every other medical problem.  


I will tell you that last year when we did a survey of Attitudes Towards Psychiatry, 41% of respondents thought psychiatry records should not be segregated.

Electronic Health Records (EHRs or EMRs) . . .

should not contain any records of psychiatric illnesses and treatments (including medications) even though that means my primary care doc or ER doc wouldn't know about my meds or condition unless I tell them 89 13% should have separate and higher protections for mental illness than for other health problems 218 32% should exist for psychiatry exactly as all other medical records do, with the same protections as for other health condition, because adding special protections increases stigma against mental illness 275 41% should allow patients to control which information they wish to be shared and with whom for all medical specialties 290 43% facilitate better communication and improve psychiatric care 261 39% negatively affect communication and detract from psychiatric care 49 7% I have no significant opinion about electronic health records in psychiatry 74 11% Other 94 14% People may select more than one checkbox, so percentages may add up to more than 100%. Your thoughts?

In Electronic Health Information, Who Decides Which Info is "Sensitive"?

I participate in a committee that establishes policies for our state's health information exchange (HIE). The HIE is the electronic infrastructure that permits hospitals, physician groups, labs, imaging companies, pharmacies, and others to share information about patients. The idea behind the sharing is to make it easier for your primary care doctor to share your health data (ideally, with your permission) with your cardiologist and your dermatologist. The potential benefits to this sharing include:

• quicker exchange of information than with faxing or mailing
• less likely for papers to get misfiled or lost (eg, think Hurricane Katrina)
• better tracking of who accessed what information
• less duplication of tests ("I know you had a CAT scan at the other hospital last week but I can't wait for the results to be sent to me so I'm getting another one.")
• improved coordination of care
• fewer medical errors due to more information available
• decreased liability due to sharing of important information with other providers

The potential risks include:

• decreased privacy due to potential for data breach, identity theft
• loss of data due to technical problems (viruses, hardware failure, etc)
• failure to secure data due to inadequate authentication, authorization, encryption, etc
• more errors in health record due to automated data collection processes
• increased liability due to sharing of sensitive information with other providers

I wanted to talk briefly about this notion of "sensitive health information." Our committee has spent many hours discussing what this might mean and how to define it. One view is that all health information should be treated as "sensitive," while another is that only certain categories of health information, such as mental illness, substance abuse, HIV status, domestic violence, abortion history, and genetic data, should be treated with additional safeguards against inadvertent access or disclosure. This latter viewpoint promotes the stigma about mental illness that we have been trying to erase.  It wasn't so long ago that epilepsy and cancer might have been on this list. My viewpoint is that patients should be the one to decide which elements of their health information should be treated with extra precautions and which should be considered routine.

This was ultimately agreed upon by the other committee members, but it still didn't help us much because the technology for patients to review their health information and mark which bits should be tagged as sensitive is not yet built into nearly any of the electronic health record products or the HIE systems. There is no standard for doing so nor is there even any agreement about how or whether it should be done. Groups like healthdatarights.org and speakflower.org have promoted these ideals, but we are not much closer to achieving them.

Anyway, I discussed this topic in my Shrink Rap News blog post this week over on Clinical Psychiatry News. Read more about it over there. If you are a psychiatrist, log in or register on CPN and join the discussion (my mistake -- other professionals and also consumers are allowed to register over there).

Podcast 54: Tell Me! Information and Technology

Welcome to Podcast Number 54: Tell Me! Information and Technology

Here's what we talk about:

Roy talks about the Maryland Health Information Exchange (HIE) called CRISP, which stands for Chesapeake Regional Information System for our Patients. Note that your health information is accessible to participating health care providers unless you opt out. You can read more at CrispHealth.org. We ramble about the downside of sharing health information electronically. We also complain about how difficult it can be to get medical information now, so there are pros and cons.

Roy talks about career satisfaction of psychiatrists based on a survey done by Epocrates. Roy talks about the increasing job satisfaction of primary care docs -- it's going up! In psychiatry it's also going up, based on data now compared to 3 years ago. Happy shrinks are up to 83% from 70%. Roy encourages med students to join us. Dinah extols the wonders of the diversity of psychiatry. Read the article about the survey Here.

Dinah brings up the age old dilemma of how to write about clinical information in psychiatry without compromising patient confidentially. We talk about how we deal with this problem in Shrink Rap: Three Psychiatrists Explain Their Work. Ah, but it's not just printed matter, but blogging and tweeting and podcasting.

Finally, Roy talks about healthcare providers and social media, referencing an earlier blog post on What To Do When Your Patient Friends You On Facebook.

Once again, thank you for listening and please do write a review on iTunes.

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This podcast is available oniTunes or as an RSS feed orFeedburner feed. You can also listen to or download the .mp3or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening

Send your questions and comments to: mythreeshrinksATgmailDOTcom