E-Rx F/U and Confession

This is a practical follow-up to my recent post, Erx Me.

I went through the E-Rx validation process at Practice Fusion. It involved submitting a very simple form, along with my medical license and government issued ID. The instructions were a little confusing, because it asked for a valid medical license, so I wasn't sure if that meant a copy of the license, or the registration, which has the valid dates. I live-chatted with them, and they were immediately responsive, and told me I could use either, and they would verify the dates.

It was a bit difficult to find the right place to submit it, but I got there, eventually. I apologize but I don't remember exactly how I found it.

The instructions said it could take 7 business days to complete the validation process, or more if they were particularly busy. I got confirmation the same day.

So, thus far, overall, Yay! for Practice Fusion.


I also tried to register for I-STOP. But I have a confession to make. I terminated my membership in the APA a year ago. I felt that they were just extorting money for CME, and that my money was better spent on something like UpToDate. Also, they implemented the MOC PIP program, which I find unacceptable.

But I still seem to get emails from the NYSPA, which is how I found out about I-STOP. Of course, since my membership expired, I can't log in. So I wasn't able to register through the NYSPA site for I-STOP.

Well, after some fumpfing around online and fuming at the idea that I might have to rejoin the APA for something that is required by law, I discovered that I didn't need to register through their site. In fact, I didn't need to register at all, since the Prescription Monitoring Program can be accessed through the NYS DOH portal. And I already have an account there, since that's how I order my prescriptions.

The instructions  for finding it were moderately helpful. You log in, click on the "Applications" tab at the top, click on the letter "P", and then scroll down to the PMP Registry. That part was easy, once I found the right instructions. As a bonus, the link to order new prescription pads is right below it.

I was then instructed to click on the green "+" sign to the right of the link, to add this to my favorites. I did so, several times, and my favorites still says it has nothing in it.

Summary: It's pretty easy to get started with E-prescribing through Practice Fusion, and you don't need to register for the Rx monitoring program through NYSPA.

Just FYI.

Erx Me

In case you thought you were done with big practice changes, s/p CPT, DSM-5, think again.

"Starting August 27, 2013, all physicians who prescribe Schedule II, III and IV controlled substances will be required to consult a new online state registry designed to track the prescription and dispensing of controlled substances."

This is from the NYSPA's comment on the new I-STOP law.

Here's a good I-STOP resource, from the Medical Society of the State of NY.

From what I can tell, starting on August 27th of this year, when we write prescriptions for controlled substances, we will have to open up our laptops or ipads or whatever, right there with the patient, and check that the patient is not up to any funny business with his meds.

I'm assuming this because of the phrase, "real time", which is supposed to be defined in regulation.

So, here you are, in your office, and you look up the patient on the registry, and you say, "Mr. Patient, it seems you've been diverting your meds, so I can't write that prescription for you. Have a nice day."

I don't know. The level of monitoring is getting out of control. It's like legislative OCD. And it carries such righteous indignation. We're going to purge the country of the evil of prescription drug abuse. Yeah, okay. It's a problem. But it doesn't have to be the Spanish Inquisition.

And it's one more way the government is insinuating itself into the room with the patient. Others include implying the psychiatrist is not doing a good job unless the patient is filling out checklists, and requiring patient reviews (see this post).

But that's not all. Starting on December 31, 2014, ALL prescriptions will need to be submitted electronically.  I was trying to figure out how to implement this, and I know, from risk management classes, that electronic medical records are a no-no, since, even if you can guarantee security (and really, you never can), if the data is stored in the cloud, you don't know who owns it. So I figured there're going to be some problems with e-rx's, and I called my carrier to find out if they have any advice about potential pitfalls, etc. They didn't have a lot of information, but referred me to the AMA's website, for  A Clinician's Guide to Electronic Prescribing, which was actually not that easy to find through the site, and I ended up googling it.

What WAS relatively easy to find was their e-prescribing learning center, where you can learn about how great e-rx is, and how it will solve the age-old problem of illegible prescriptions. You can also learn about how much it will cost you to implement and maintain your e-rx system. In fact, it'll walk you through a series of questions to help you determine which system is best for your practice. And then it will give you a list of e-rx systems that meet your needs.

I tried it, and I answered all questions on the "no frills" end, i.e., I don't want any advanced features, I don't want an EMR to go with it, etc. It came up with 3 recommended systems:

Relayhealth Escript at $600, no demo available
Care360 Physician Portal 2008.3, at $240, no demo available, and
InfoScriber, version 115, at $600, no demo available

Now, I didn't try to look this up, but I'm willing to bet that the AMA has financial connections with all these systems, and any others it spits out. It certainly didn't refer me to Practice Fusion, which is free, comes with an, also free, EMR which you don't have to use if you don't want to, and is ranked #1 for both e-rx vendors, and EHR based e-rx vendors, by the Black Book Rankings.

Bottom line: I signed up for Practice Fusion (no, they're not paying me to write this), and I'm in the process of being verified for the e-rx (apparently, you have to do that). I'll let you know how it goes.

As I was writing this, it occurred to me that once we start e-prescribing controlled substances, we'll be taking diversion of these substances out of the hands of individuals who have to hustle to get hold of a one-month supply of meds, and placing it in the hands of anyone savvy enough to hack the system. Who could do that? Oh, I don't know, maybe a large scale crime organization, or your average computer science major at MIT. Goodbye, diversion in dribs and drabs, hello big-time diversion.

On Call

Like Dinah over at ShrinkRap, I'm fed up with DSM-5, CPT. EMRs, RDoC, APA, E-rx, AMA, and NiMH, even if I could find Mrs. Frisby there.

So what to write about?

When I was a resident, I starting writing little vignettes about my experiences taking call. Eventually, I had written enough of them that I thought they would make a nice book, On Call: Stories from a Resident's Night. I never published it, although I may self-publish at some point. But I thought I'd share a chapter.

It was intended for a lay audience, so there're some explanations that people reading this blog probably don't need. But I'm guessing people will relate to the experience.



Spitback Dose

I'm in the ER on a Sunday evening, maybe 7PM. A guy comes in, typical story- suicidal, heroin addict, HIV positive. 
I go through my usual routine of checking the computer system for any previous admissions.
Yup. He’s been here before, but not on psych. He was on the detox unit. 
Aaaaand, he was discharged today. At 3PM. 
You know what? His chart is probably still on the unit. I'm gonna run up there and get it, before the chart fairy spirits it away to medical records, where it will serve its obligatory 5 to 10 months under a pile of disoriented neurology charts.
I head up to the detox unit, and sure enough, it’s there. I start to read.
Admitted 2 days earlier for heroin detox. Administratively discharged. That means they kicked him out.
Why?
For giving a spitback dose of methadone to a female patient, in exchange for sexual favors.
What’s a spitback dose?
I have no idea. Or, more accurately, I know exactly what a spitback dose is, and I don’t want to believe it.
I try to imagine the routine on that floor. The guy comes to the nursing station. He’s given his dose of methadone in a little paper cup. He gulps the contents quickly, in front of the nurses, but keeps the liquid in his mouth. Then he shuffles down the hall, past where he can be seen by the staff, and spits the dose back into the cup.
He then hands the cup to a female patient, who downs it, HIV-infused spit and all, and proceeds to blow him in the bathroom.
Yuck!
The thought of the blow-job doesn’t bother me, but I’ve always been kind of grossed out by saliva related substances. I’m grateful I’m not a heroin addict, because the choice between getting my fix, and drinking someone’s spit would be a rough one for me.
I’m not sure how the staff found out about it, but I don’t care. Now I have my ammunition. I can easily convince the ER attendings that this guy needs to go. And I don’t have to admit another lying, conniving, manipulative drug addict to my pristine unit, and get blamed by the attendings for not being sufficiently selective. 
I repeat to myself my ER mantra: “I, am a wall!”
I’m practically skipping when I get back to the ER. I see the head nurse, H, who has worked here for years and who’s seen everything. 
Everything minus one, as it turns out.
I tell her about the spitback dose. She has the same reaction I had, “What’s that?”
I explain. 
She’s incredulous. 
I say, “No, really.”
She says, “Oh my god!”
As I’m walking away, she pulls over one of the other nurses and says to me, “Tell him about the spitback dose!”
She repeats this process 5 or 6 times during the course of the call. I guess she’s also surprised that she hasn’t seen everything. I have my 15 minutes of fame that night, and I repeat another mantra: “You can’t make this stuff up.”

The information I have about this guy, however juicy, does not absolve me of the responsibility of evaluating him for admission. So I call him into the office. I leave the door open. He’s jumpy and scary looking. He obviously needs a place to be, and probably doesn’t have money for more drugs, so if he’s not in a hospital, he’ll have to tough out a cold turkey detox. 
I look at his eyes. The pupils aren’t pinpoint-sized, which means he hasn’t been using. And they’re also not inordinately wide, which means he’s not in any significant withdrawal yet. None of which really means anything. 
Addicts know how to fake withdrawal symptoms, so they can get an extra dose of whatever, to keep them comfortable. If they want to be sweaty, they do some pushups. If they want widened pupils, they go into the bathroom and leave the light off for a few minutes. If they want goose bumps, they douse themselves with cold water until they start to shiver. If they want to vomit, they stick their fingers down their throats.
The detox staff knows all these tricks. In fact, if the patient complains of needing an extra dose of methadone because he’s had diarrhea, he won’t get it unless said diarrhea is still in the toilet, and the nurse has verified it.
It always amazes me how the extremes of pain and mental suffering are so intimately connected with bodily substances.

I ask the guy why he’s here. He says he’s depressed, and he wants to kill himself, and he needs to stop using. It’s the standard FOS line. Unfortunately, it’s also true. But the bottom line is that this man is a survivor. He gets kicked out of a hospital for unacceptable behavior, and 4 hours later he’s back, unabashedly seeking admission again. He probably does want to kill himself. But he’s not going to. He’s too precious to himself. 
Could I be wrong? Yeah. Could this be his end of the line, and I’m just too jaded to see it? Sure.
But I’m probably right. And a hospital is not a hotel. You can’t just check in when you run out of money and drugs, and expect 3 hots and a cot. It’s a place for people who are genuinely ill (which this guy is), AND ready to try to do something about it. I don’t think 4 hours is enough time to become ready.
But there’s another reason I don’t want to admit him. I’m tired of being taken for a sucker. The 4am Xanax runs. The FOS malingerers. This is my turf, and I’m gonna defend it. I am a wall. I don’t let the enemy pass unchallenged.
And this time I’ve got the facts on my side. Even the most conservative ER attending won’t mind kicking this guy out, to say nothing of Dr. C, the hyper little man who once yelled at a malingering patient, “Get out of my ER! My tax dollars are not paying to support your drug habit when you run out of money for food!”

I ask Mr. Spitback a few more questions about his medical and psychiatric history, then I tell him I need to talk to my supervisor. I have not told him I read through the chart from the detox unit. I don’t want to introduce this topic with no one else around. He’s denied having been here recently, so he’s outright lying.
I get the attending, and together, we explain to the man that we know about what happened earlier that day on the detox unit, and that he’ll have to leave. We try to get him to sign the discharge papers, but he refuses. We walk away while he’s gathering his stuff.
As he walks past me, on his way out, he yells, “I hope your husband fucks you real hard up the ass!”
I pray I never see this man again, particularly in a dark alley. At the same time, I realize that in his life scheme, I’m not very significant. He’s been kicked out of places before, and he probably wouldn’t even recognize me if he saw me. 


This vignette was the most difficult one for me to write. At first I thought it was because it was unnerving to experience an attack so infused with fury and hatred. When it happened, I even briefly considered calling security, or the police, to show this guy he can’t treat me this way. And who’re they gonna side with? A female physician, or a male drug addict? They’d probably beat the shit out of him.
But I think it’s more than the fact that it was scary. I’ve had other scary encounters with patients. I’ve even been hit by patients, on two separate occasions.
What bothers me is that this man came seeking help, came to a hospital, a place of healing and comfort. And instead of being helped, he was treated like the enemy. I don’t think the hospital has the resources to deal with his problems. I know I don’t. But this doesn’t imply that he should be demeaned, or viewed as an enemy. 
What hurts is how easy it was for me to lose my sense of compassion in order to protect myself from feeling helpless.

CPT-New and Improved?

In response to my recent CPT article, CPT: A Primer, in The Carlat Report, I received an email from Joel Shield, MD. I don't know Dr. Shield, but I want to share some of the content, and I have his permission to do so.

Dr. Shield writes about the real CPT coding, as opposed to what's being presented as CPT coding, which is really the Center for Medicare Services' (CMS) version, the version I've researched and written about because I didn't realize there was a difference.

What is the difference? Basically, the CMS version is a checklist, with, for example, 1-3 elements of HPI, at least 6 elements on exam, and 1 pertinent ROS for a 99213 (see my post).

But the version from the CPT 2013 manual is much more descriptive. You have to meet the same standard-providing enough information to qualify your coding, but it's much less of a checklist.

I'm not getting into too much detail because that might involve purchasing the manual so I could figure out what goes into it. Dr. Shield forwarded two articles he wrote up about the coding, and I'd like to include them, but I haven't figured out how to attach a pdf to a post. If anyone knows, by the way, please comment and tell me how.

However, a nice summary was included with the email I received:


In summary, the CPT manual and the CMS guidelines use the same categories for coding E&M services (the four levels of history, examination, and medical decision making), but differ significantly in some of the details of those categories (for example, the CMS guidelines specifying psychiatric, constitutional, and musculoskeletal parts of the psychiatric examination) and, most importantly, in adding a sub-basement level of very detailed requirements for what defines the levels of history, examination, and medical decision making. While the descriptions of the levels in the CPT manual are, in general terms, the same as those of CMS, because they are more descriptive they can be satisfied more flexibly and more easily. 

Now here's the rub: If you document more descriptively, you can be less freaked out about what goes into your documentation. You might even be able to write the kind of note you're accustomed to, one that has something to do with patient care. But, if you ever get audited, or need to justify your services to someone who may or may not have graduated from high school, someone who is simply going to count the number of bullet points you did or didn't include in your documentation, then you're better off having bullet points to be counted.

To be honest, I'm bugging out a little over all the recent changes. You need to bill differently, and learn how to bill differently. You need to diagnose differently, and learn how to diagnose differently. It's too much. I'd really like to get back to my day job.

Quick Link to Book Review

Here's a review of The Book of Woe: The DSM and the Unmaking of Psychiatry, by Gary Greenberg. For those who want more on the DSM-V saga.

The Other Winner

I haven't forgotten my promise to review the winners in my survey. Survey takers, god bless you, voted for chapter rearrangement as the change in DSM-5 that would do the most good. You can link to the full Table of Contents from here (sorry it's indirect).

Looking over the chapters there's really a lot to cover, especially if I'm trying to compare with DSM-4. So I thought I'd start with just the first clinical section in each.

DSM-5 begins with the general heading, Neurodevelopmental Disorders, and this section is broken down into subsections (which are further broken down). They are:

• Intellectual Disabilities
• Communication Disorders
• Autism Spectrum Disorder
• ADHD
• Specific Learning Disorder
• Motor Disorders
• Other 

The corresponding section of DSM-4 is called, Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence with these sections:

• Mental Retardation
• Learning Disorders
• Motor Skills Disorder
• Communication Disorders
• PDD
• ADHD
• Feeding and Eating Disorders of Infancy or Early Childhood
• Tic Disorders
• Elimination Disorders
• Other

I'm not sure which I prefer. In DSM-5, Tic Disorders are included under Motor Disorders, rather than having their own section as in DSM-4. Learning Disorders are broken down into specific disorders in DSM-4, while in DSM-5 they're not. And, of course, DSM-4 includes multiple Pervasive Developmental Disorders, where DSM-5 groups all under the heading of Autism Spectrum.

In addition, DSM-5 puts all feeding and eating disorders, regardless of developmental stage, into their own section, entitled, unsurprisingly, "Feeding and Eating Disorders", and this section occurs much later in the book. It's immediately followed by the Elimination Disorders section, which removes the implication of these as childhood disorders.

So it's looking like DSM-5 does more lumping, where DSM-4 did more splitting. But that's not entirely consistent.

And you have to admit, there's a nice logic to following the Eating chapter with the Elimination chapter.

One thing I do like about the chapter organization in DSM-5 is that, unlike DSM-4, Neurodevelopmental disorders, which are basically childhood disorders, are not followed immediately by delirium and dementia, disorders of old age.

I'll cover more in future posts because it's getting past my bedtime.

And In This Corner....

Get ready to rumble!

Meet the contender: Thomas Insel, MD of NIMH

And the reigning champion, David Kupfer, MD of the DSM-5

Dr. Insel comes out swinging with the Research Domain Criteria (RDoC), the project launched by NIMH "to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system."

And, wait for it, "..it is critical to realize that we cannot succeed if we use DSM categories as the 'gold standard'...The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories."

Ooooh, low blow.

Now Dr. Kupfer counters with, "Efforts like the National Institute of Mental Health’s Research Domain Criteria (RDoC) are vital to the continued progress of our collective understanding of mental disorders. But they cannot serve us in the here and now, and they cannot supplant DSM-5. RDoC is a complementary endeavor to move us forward, and its results may someday culminate in the genetic and neuroscience breakthroughs that will revolutionize our field. In the meantime, should we merely hand patients another promissory note that something may happen sometime?"

Dr. Insel staggers backward into the ropes. He's covering up with his gloves. But wait, he shoves Dr. Kupfer away and pummels him with, "That is why NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system."

And Dr. Kupfer is down! The grant money gets 'em every time.


* I hope the Ali-Frazier image is old enough (1974) to be off copyright. If not, I'll promptly remove it, with my apologies.