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Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.


Friday, August 15, 2014

K'vetch Fest 2.0

First off, let me apologize for the radio silence. I've been on vacation, literally and figuratively, and I haven't been able to get myself to so much as look at a draft of a post, let alone work on one, or even read the usual blogs I follow, with the exception of my favorite crochet blog. That's how mindless I've been keeping things.

Mea culpa.

Moving on, I'm going to pick up where I left off on a post I started before vacation.

In the mid-70's, the comedian Alan King had a TV special called, "Final Warning", in which he joked about everything that was wrong with the world. The next year, he had another special called, "2nd Annual Final Warning", and the year after that, "3rd Annual Final Warning."

It's been a year since I wrote The Culture of Medicine and the Art of Kvetching, in which I asked the age-old question, "How did we get to this place?" And I listed a few of the things that make practicing psychiatry a crazy endeavor. And I know crazy.

Last year's list, in brief:

DSM-5
E/M coding
I-STOP
MOC
HIPAA
EHRs
Insurance Companies
SAFE

Well, a lot has happened in the past year. The concerns that plagued me then have evaporated, while other woes have befallen me. Here's a partial list of what's bothering me now:

MOC
ERx
EHR's
Collaborative Care Model
ACA
Insurance Companies
+/- ICD-10
DSM-IV vs. DSM-5 on the board exam
Big Pharma not releasing data
HIPAA

Oh, wait. I guess not that much has changed, after all. E/M doesn't bother me anymore because I use a template for notes, which make my notes completely meaningless, and I'm pretty much on autopilot. In fact, I'd have to reread my own post if I wanted to remember the nitty gritty of coding.

The NY SAFE gun act that is supposed to prevent the "dangerously mentally ill" from obtaining access to firearms has simply not been relevant in my practice, and I hope it never becomes so. And I-STOP is now I-Just Do It and I-Don't Care.

Beyond that, it looks like things have gotten worse. HIPAA is still on my list because now it's not clear if doctors who prescribe electronically, which will be all doctors starting in March, are subject to HIPAA. I got a letter from my risk management about this the other day. They're researching the eRx issue, and they also sited cases where there were breeches of security because some management bozo left 70 boxes of medical records out on the street. Ya think?
They also wrote about the lack of security for those who somehow still use Windows XP, now known as Windows RIP. Mac rules!

EHR's are still worse than useless, and the CDC has been actively pursuing me to get my opinion on a "brief" and "voluntary", but not "anonymous" survey. Seriously, I mean stalking. I got one copy of the survey, which sat on my desk while I contemplated whether I would fill it out. A week later I got a postcard reminding me to fill it out. That's when I placed it in the circular file. I've since gotten two more copies of the survey, and two irritated phone calls.
I thought about filling the thing out. It asked about whether and how I use an EHR. I had some qualms about chucking the thing because if I'm really concerned about the use of EHR's, then I should fill out the survey and express my opinion. But it didn't really provide a way for me to describe the fact that I have an EHR, but I don't use it, and the only reason I have it is because I don't want to have to pay a lot of money to e-prescribe, come March. It also wasn't anonymous, and asked some stuff related to meaningful use that seemed like a good excuse for private insurance companies, in the not-too-distant future, to reimburse less for doctors who don't use EHRs, consistent with medicare/medicaid policy. And they were a little cagey in their description of how the information was to be used.

I thought I was good with the Erx situation, but it turns out I need to re-verify my credentials. And I may have used up the three chances I get to do so, because I started the process at work, and then realized the answers to some of their questions involving old mortgages and addresses were at home. I'm gonna try again, but if it doesn't work, I'm not sure what I'll do in March.

The Collaborative Care Model makes me want to cry-I have half a post written about it, so maybe I'll share that if I can finish it. And I don't understand why no one of importance has come out and stated that the reason Big Pharma is withholding its data is because they're worried that if they reveal the full data, people will realize that their drugs either don't work, or are harmful. Or both.

But the big one, of course, is MOC. I registered for my exam today. I put it off as long as I felt I could tolerate, but I finally bit the bullet and did it. All $1500 of it. I did read through the terms pretty carefully, and even though I've agreed that the board can decide my test results are invalid, even if they don't think I did anything wrong, I did notice that that particular clause does not say anything about my needing to pay to retake the exam under those circumstances. It doesn't say I don't need to pay, either, but at least I can make an argument for myself. Yup, that's how positive I'm feeling about the experience.
And a few days ago I ordered the cheapest version of DSM-5 that I could find. That would be the Desk Reference to the Diagnostic Criteria from DSM-5(TM) (Paperback), which set me back $26.27, as opposed to the $62.02 spiral-bound version. It's sitting in an unopened box on my desk, along with a bottle of granite cleaner. I felt like there was no way I could figure out the changes from IV to 5 without seeing 5. But it pains me.

So once again I ask, "How did this state of affairs come to be?" You know how there are legends about babies being trained to be Ninjas, and their parents dislocate their shoulders for them so they can do it more easily as adults, and get themselves into or out of tight spaces because they can contort themselves unnaturally? Well maybe there's a cult of some kind that drops babies on their heads or deprives them of oxygen so they can grow up to make rules about insurance coverage. Or come up with systems of psychiatric care that have everyone BUT psychiatrists seeing patients.

There's a Talmudic phrase that applies here. Roughly translated, it means,

The world has been given over into the hands of idiots.



3 comments:

  1. Do you think that EHRs are problems for all specialties or just psychiatry? A lot of them seem useful for primary care, since you can have a handy checklist at the top of what health screenings have been done etc.

    I get why it would be a pain for an analyst in solo practice, but they seem helpful in hospital settings. I mean, I worked at a mental health unit in a public health State Hospital which didn't have one, and it was horrible. Somebody who had worked at a mental health hospital run by the department of mental health said that it blew her mind. There was an EHR with some notes, but it was hard to look up the treatment plan.

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  2. I really can't speak to their usefulness in primary care, but from what I've seen, most EHRs are designed to make billing easier. If I could program, I would design something a lot more user-friendly for doctors. Also, they cost a fortune, especially in hospital settings, and it's not clear, from what I understand, that they do any real good for patients. The one I have seems very cumbersome, regardless of specialty.

    There's also the issue of storage of patient data, and who owns it-the doctor, or the EHR company.

    I think it's possible to design a really good EHR, but it needs to be easy to individualize. Again, if I could program, I'd attempt it and make it open access. But my programming days are long gone-last time I wrote something was in the '80s.

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  3. Thanks for your thoughts. Some of them are pretty cumbersome. I do know someone who said that his kid's pediatrician was a bit of a geek who liked to write macros for the EHR he used.

    As for the data issue, I think that in our case the State owned the data, although weirdly the psychiatrists did not work for the State but an agency.

    The State bought software, not an integrated software/storage solution. Only about 40% of the stuff was in the electronic record though...That was the clunkiest thing I've ever seen.

    A friend of mine was an IT guy before he became a psychotherapist (social worker who doesn't have to deal with prescriptions, obviously). He had everything electronic once he set up a private practice, just because he preferred it that way. But I think he just picked out something that was very similar to how he would have taken notes anyway.

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