Faber Healthcare Solutions

It can be a frightening time to be a physician; liability insurance costs are climbing, regulation is increasing, patients’ expectations are often unrealistic, and the doctor is still a human being, prone to human error. True, there are technological advances that help guide physicians along a safe path in clinical care, such as electronic medical records, and drug interaction databases, but at the end of day doctors still worry about being sued.

So how can you help protect yourself?

• - Keep good, easily legible, and easily comprehensible records. The best practice here is to get an EMR. Short of that you should write clearly and present your thoughts in an organized fashion. If your writing is so bad that even you cannot read it yourself, and you do not want to spring for a computerized system, dictate. Worse than being sued, is being asked on the witness stand to read your own note and flinching – by then, you’re sunk.
• - Prepare to apologize. Lawyers cringe at this advice, but doctors who admit their errors, particularly the little ones, and treat the patient with respect and apologize, tend to get sued less frequently. Some organizations, such as the VA, have adopted this guideline as policy, and the number of suits has fallen since its implementation.
• - Explain clearly. Tell the patient what you want to do, why you want to do it, and, if appropriate, why you will not do what they want you to do. Explain what the next steps will be, if your initial treatment is successful, and if it is not. If a patient is concerned about the treatment, explain why those concerns are unfounded, or why they are reasonable but are less concerning than not treating. You will still have unhappy patients, but they will have more reasonable expectations about the outcome, and therefore less likely to run to an attorney.
• - Communicate. When a patient is concerned about his care, he will contact your practice. Call him back promptly, at a reasonable time, and with enough time to converse properly.

With these tools, you can minimize your risk of malpractice lawsuits … and also increase your patients’ satisfaction.

An online PHR is nothing more complicated than a web-based repository for a patient’s own medical history, including allergies, hospitalizations, vaccinations, surgeries, medications, tests, and family medical history. This is exactly the kind of record that every person should have, as it is invaluable during examinations and emergencies. However, having that information online is concerning.

• - Access to the data, and the integrity of the data itself, can be compromised by server failures.
• - The data itself may be vulnerable to hackers or other unauthorized access.
• - The server, and the company that owns it, may be offshore, and not subject to US law.
• - Even if the server is in downtown Dallas, the data on it is not subject to HIPAA’s privacy regulations, which protect a patient’s personal health information at a doctor’s office or hospital.
• - The data could be subject to subpoena, by courts and insurance companies.

There are a couple of industry titans developing online PHRs. Microsoft has HealthVault, and Google has developed Google Health. Both packages are currently in beta release.

There are alternatives to online PHRs without sacrificing the technological benefits of computerization. There are PC-based systems, which help patients organize their information, enabling them to print it out, put it on a disc, or email it to their provider. Similar software is available embedded on portable flash memory drives, some with data encryption.

Both these systems have risks, such as loss of data, potential privacy concerns, and physical loss of the drive or disc. However, the data under greater control of the owner that web-based systems, cannot be subpoenaed, and do not merely rely on the person’s memory at a fixed point in time.

The New England Journal of Medicine published a study this week about the efficacy of home defibrillators, just one day after the American Heart Association released new CPR guidelines.

The Associated Press published an article today, titled “Home Defibrillators Save Lives in Study.” Sounds promising … until you read the first sentence. “Having a defibrillator at home can help a heart attack survivor live through a second crisis, but so can CPR and at a much lower cost.” Which CPR are they referring to, the new method or the old one? And while both CPR and defibrillators work, is one better than the other? Let’s waffle. As Dr. Bardy, the study’s lead author said, ”There’s no downside’.’

Yesterday the New York Times published a column about the same NEJM study, titled “Few Lives Saved by Home Heart-Starting Devices.” Seems to have an opposing interpretation of the same study. Nope. It also concludes that the device and CPR save lives at the same rate: “But the study, of more than 7,000 heart patients, concluded that patients in homes equipped with the gear died at the same rate as those without it.” At least this column comments that the devices cost about $1500 apiece, considerably more expensive than, say, the hands the CPR-performer was born with, and considering the results were identical that makes owning a home defibrillator an inefficient use of resources. The article quotes Dr. David Callans, a professor at UPenn, who commented on having a policy of home defibrillation devices, saying “It’s a great example of what is wrong with American health care.”

The New York Times carried both articles on the same web page. Hmmm.

One of the gaping holes in American residency training is the utter lack of business training. Today’s physicians graduate from medical school having learned the cutting edge of medical care. Of late, residency programs have learned the value of patient relations, and have successfully integrated humanism courses into the educational framework of residency. Unfortunately, many new physicians are launched into the workplace ill-prepared for the business of healthcare.

Graduating residents have told me that they have great anxiety over their graduation, not because their medical safety net will be removed, but because they feel unprepared for their upcoming roles as business owners and bosses. Recent graduates have told me that they felt their residency programs let them down by not providing proper education about the business of healthcare. Established physicians have told me that it took them many years to learn, through trial and error, how to run their businesses. They also admitted that there were many more errors than they would have hoped, and that they remain unsure if their acquired knowledge is even correct.

It is heartening, however, that today residency programs are aware of this shortcoming, and are taking strides to remedy it. In fact, I have been invited to speak to medical residents at a number of major NYC academic medical centers in the coming weeks to supplement the young business awareness programs these schools have begun to implement.

The previous generation of physicians had a rude awakening, following the Reagan years, of the realities of medicine as a business. All signs indicate that the next generation of physicians will be better prepared, and I sincerely hope that is the case.

There has been a recent explosion of walk-in health centers, such as Minute Clinics (recently bought by CVS). These centers charge a flat fee, usually $45-$65, for an appointment-free quick sick check, what Wal-Mart, in its centers, calls a “get well” visit. Such centers are utilized not only by sick adults, but also by parents for sick child visits, even though the centers are almost never staffed by physicians, only nurses and nurse practitioners.

There has been much debate as to the propriety of these centers. Advocates say that it allows patients to obtain quick, high-quality care, and allows them to get back to other important activities in their lives. Detractors voice concerns that these quick visits to non-physicians risk missing more serious conditions.

Additionally, and perhaps amazingly, in a recent survey by MSNBC, 35% of patients who utilize these centers are insured, and came to walk-in health centers instead of their own doctor, even though the centers do not accept their health insurance plan. Surely the wait time, plus the rising amount of copays, have swayed them.

Walk-in centers certainly pose a challenge to the conventional medical practice, particularly in pediatrics. Pediatricians must begin to offer similar services, including quick appointments with little waiting time, at a competitive price. The price is certainly a sticking point: fee-for-service practices cannot subsist on $60 sick visits, certainly not when that price includes a rapid strep test, and providers who participate with managed care have no control over the patient’s copay amount, which may likely approach $40 or $45.

To remain competitive with these services, physicians will have to foster quality relationships with their patients, a relationship that patients not only appreciate but also rely upon, one that patients value over the cost savings of a walk-in health center, as well as provide timely appointments … or their patients will start to walk, and follow their wallets.