Diary of Medical Management Issues

                                            1.

When healthcare uses the word “compute...
3.

One of the main and understandable concerns of online healthcare information is security
breaches. Personal Health Inf...
Continued…
her assessment. When I returned on Monday, the patient was still in-house. When I
reviewed her chart I found th...
8.

Every morning our offices (as Priority Healthcare) phoned the discharge facilities to
record what kind of open beds we...
Continued…
I called the night nurse around 9 pm to make sure the schedule was being followed and
the nurse told me that th...
14.

When I was reviewing for Insurer, I was called by the hospital case manager about a
patient whose hospital days were ...
17.

Morbidly obese patients are difficult to place in a discharge facility due to the fact that
their weight puts a strai...
Continued…
patient had a bowel movement (with the aid of stool softeners or laxatives/enema) this
would save expensive re-...
Continued…
health monitoring device which takes blood pressure, heart rate, temperature, blood
glucose levels all at once,...
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Diary Of Medical Management Issues 1

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Diary Of Medical Management Issues 1

  1. 1. Diary of Medical Management Issues 1. When healthcare uses the word “computerized” this means healthcare providers using technology as a “notebook” to transfer previously handwritten clinical information into electronic documentation. This is not only an ineffective effort that falls short of our technology capabilities but can actually increase manual demands for computer entries. When software engineers and internet companies use the word “computerized” their industry means something far more useful… that electronically stored information is “actively managed” to replace costly workforce, connect and unify services and products, decrease marketing budgets, providing reliable monitoring that the incidence of human error cannot achieve This is a successful use of today’s technology that our healthcare system has not utilized. Our software (Medrok, Inc.) product melds healthcare expertise with technology expertise; a type of “artificial intelligence” that uses the stagnant “notebook” information to produce solutions. For example, a hospital requires nurses to engage in computer entries every two hours on multiple screens replacing previously handwritten notes. Some of this information is still recorded in paper charts. Dividing electronic and paper documentation only leads to further incidence of errors and omissions. Another example is regarding pharmacy prescriptions. Currently a physician must write a paper prescription that the patient must take to the pharmacy or the physician’s office has to call the pharmacy to place a prescription. Many times there are delays or miscommunications in these phone calls or written prescriptions that delay the initiation of proper treatment for the patient. Such delays can precipitate further medical deterioration which increases cost of treatment. Our system utilizes computer entry of prescriptions that with a secure authorization will allow pharmacies to retrieve electronic prescriptions and refills online. 2. Ask yourself why our auto industry is required to provide estimates and reveal costs of auto repair upfront prior to providing services and our healthcare providers and insurers are not. Providers and insurance companies do not inform the patient of their costs before expensive procedures, surgeries, treatments and demand that patients sign “blanket” statements making them legally responsible for amounts that they are not capable of paying. This means the provider of services such as physicians, clinics, hospitals, pharmacies are not reimbursed by the patient thus our healthcare system falls deeper into deficit and collapse. All healthcare services and products (except for emergency services) should be pre-authorized and an upfront estimate provided to the patient. It is unacceptable that we are managing our auto repair industry more responsibly and efficiently than our healthcare.
  2. 2. 3. One of the main and understandable concerns of online healthcare information is security breaches. Personal Health Information is protected by strict governmental guidelines known as HIPAA Regulations which impose severe criminal punishment. Due to technological advances that allow the fingerprint and further password requirements to be to access restricted online information, along with advanced encryption capabilities and “shelving” or inactivating online information, our software system will protect healthcare information more rigorously than phone calls, faxing or paper trails. We will complete the programming of our software utilizing government supervision on every level and obtain a HIPAA Compliant Status. 4. A personal example regarding poor medical follow-up and how it increases costs. Recently, I contracted a urinary tract infection. I went to a clinic and a urine culture was taken and I was started on an antibiotic and an anti-spasmolytic. By the sixth day my symptoms were not improving and I called the clinic multiple times to request my culture results and to inform the physician that I was developing a fever, chills, nausea and flank pain. These are all indicative of a urinary tract infection progressing to a kidney infection which can require hospitalization and IV antibiotics. The office staff took my information and it took them over a day to call in a change of antibiotics to the pharmacy. They NEVER gave me my culture results. The physician never spoke with me directly despite my repeated efforts to reach her. This is not uncommon. Due to the fact that the physician never followed up with me (and thank goodness I am in the healthcare field and know the signs and symptoms of a kidney infection and repeatedly called them for further treatment) I could have developed a serious, costly kidney infection. The change in antibiotics resolved my symptoms after a 10 day course but I literally had to sit at the pharmacy waiting for the physician’s office to call in the prescription change sweating and in severe discomfort. With our computerized system, I would be able to check on my culture results and enter in how my treatment was progressing. This could have electronically alerted the physician to pay particular attention to my situation and electronically enter a prescription that could be filled immediately. Multiply my incident by thousands nationwide and imagine the cost of such negligence. 5. Reviewed patient who was a couple of days post-op hysterectomy. She also had an underlying seizure disorder for which she was on Dilantin, a medication used to control seizures. When I reviewed her on a Thursday, I noted that her Dilantin level was only 2 (therapeutic levels are 10 to 20). I checked the most recent MD orders in the chart and did not see where anyone had addressed this very low Dilantin level. I had to track the nurse down who was extremely busy and asked if she or the MD were aware of the low drug level. She said no. I asked her to inform the physician. The next day, on a Friday, I reviewed the patient again and noted that the physician had ordered an increase in the patient’s Dilantin dose. Satisfied that the patient’s issues were being met, I completed
  3. 3. Continued… her assessment. When I returned on Monday, the patient was still in-house. When I reviewed her chart I found that she had actually been discharged home Saturday with a Dilantin level of 3 (still extremely low). On Sunday at home, she suffered a grand-mal seizure, fell down during the seizure and had fractured both of her shoulders. She had to be re-admitted on Sunday. The Emergency Room had given her several doses of intravenous Dilantin to get her level back to a therapeutic range. Due to the fact that this patient was discharged with such a low, ineffective Dilantin level, she now required 2 separate surgeries to repair her shoulders. 6. With my company Priority Healthcare I was called by an LA Hospital social worker who requested assistance with a skilled nursing level patient that they had been trying to place in a skilled nursing facility bed for over a week without success. They could not find any facilities to accept the patient. I arrived at the hospital and reviewed the patient and could not find any glaring issues that would keep this patient from being accepted. So I called a couple of the skilled nursing facilities and “firmly” insisted that they tell me why they did not want this patient. They told me that the patient was on a medication that cost nearly $400.00 per month. I put the facility on hold and asked the social worker who the physician for this patient was. The physician just happened to be making his rounds and was in the nursing station. I informed him of the issue regarding the cost of the medication and he immediately and simply told me he could change the patient’s medication to an equivalent but lower cost medication. When I informed the skilled nursing facility about the change in medication, they immediately accepted the patient who was discharged that day. So this patient had been sitting in-house for over a week costing the hospital and insurer unnecessary costs. 7. I was contacted by many hospitals to speak with patients & families who were resisting discharge to a lower acuity facility because they were very distrustful of their family member leaving the hospital. At times, the patient and family would resist for days/weeks. Generally I would sit for about 45 min. with the patient & family explaining to them in detail the care and services of a lower care facility. 98% of the time, the family was reassured, with their concerns and questions answered and would then cooperatively participate in getting the patient to a lower acuity facility.
  4. 4. 8. Every morning our offices (as Priority Healthcare) phoned the discharge facilities to record what kind of open beds were available with the purpose of filling those beds. Frequently, the facilities admission department would not be able to tell us. We would have to call back several times and even then it was hard to find someone who could give us an accurate list. Currently, the discharge facilities hire marketing people to go out to hospitals with cookies and candy, but still no record of what actual beds they might be marketing. Once again, can you imagine the airline running seat reservations like this?! 9. My office staff would call RN’s each morning on every patient to discuss the clinical state and daily plan of care with the goal of transferring the patient to lower cost bed. Our organized, current updates were so efficient that the physicians began calling us for information on their hospitalized patients instead of the hospital case manager and nurse. The hospital case managers were so inefficient with clinical issues that I insisted that my staff spoke directly with a bedside nurse. The hospital’s issue with speaking to the bedside nurse was that we were interrupting their focus on patient care which is why we need to computerize the morning shift report and electronically manage clinical information. 10. Many times I was called by hospital case managers for assessment of subacute level discharge. The patient would not qualify for subacute level due to issues such as too high of an oxygen setting on their breathing machine or mild fluctuations in temperature or the patient was on dialysis as well as a breathing machine. So I had to suggest to them the changes that would have to occur for subacute level admission or I would suggest an acute long term level admission which WILL allow for higher oxygen levels, mild clinical deviancies and dialysis. 11. At an LA Govt. Hospital I was reviewing a patient for discharge. The patient was very agitated and had to be restrained (tied down by both wrists). The patient was subacute discharge level with a tracheostomy and trach collar oxygen delivery. Subacutes do not accept agitated, restrained patients as there is a serious risk of the patient getting loose and pulling out their airway. I spoke with the physician who was very eager to get this patient out and we discussed the patients sedative schedule. We discussed putting the patient on a low routine dose of Ativan with intravenous doses as needed. or to call in a Pain Management Consult. The physician decided he wanted to manage the sedation without a pain consult so I told the physician and nurse I would be back in the morning and if the patient was calm and un-restrained I could get him to a discharge facility.
  5. 5. Continued… I called the night nurse around 9 pm to make sure the schedule was being followed and the nurse told me that the physician had NOT written the change in Ativan, the patient still agitated and restrained. I asked the nurse to call the physician to get a phone order because if the patient wasn’t stabilized by morning I would not be able to get him to a discharge facility. When I showed up in the morning, the physician had still not ordered medication changes and the patient was still restrained. The physician was very upset that the patient couldn’t go out so I had to have another conversation with him about the sedation schedule. Finally, he wrote the orders. The following morning the patient was calm, unrestrained and was discharged to a subacute. 12. Some patients are prescribed Epogen for low blood levels (hemoglobin/hematocrit). It is a medication that stimulates the body to produce more red blood cells. It is a VERY expensive medication. I cannot even count the times that I reviewed a patient who was on Epogen whose blood levels had corrected themselves (and were healthier numbers than my own blood count!) but were still on the drug. I would inform the physician and more often than not, the physician would take the patient off of the drug because they didn’t need it any longer. 13. At an LA Hospital (prior to their bankruptcy and closing) I evaluated a patient in the Intensive Care Unit. I noticed that the patient’s bleeding/coagulation times were severely elevated (meaning the blood is very thin). The patient had been on Coumadin (a blood thinner) so I immediately asked the nurse if the Coumadin had been stopped. The nurse told me the Coumadin had been stopped 3 days ago. I was relieved but realized that the patient’s bleeding/coagulation levels had not dropped after stopping the drug for several days which was not normal. The nurse told me that the attending physician had ordered the patient to go to a telemetry bed and out of the ICU. I called the attending physician three times waiting nervously for a return call. Then I decided I would try to contact the neurologist who was on the case. When I spoke with him he was pretty alarmed (apparently he had not noticed the abnormal labs). He told us not to transfer the patient out of the ICU and to call a hematology (blood issues) consult right away. As soon as I hung up the phone with the neurologist, the nurse beckoned me into the patient’s room. The left side of her neck was swelling up and I questioned the patient on her airway (if she was having a hard time breathing). She turned her head to the left where we were standing and suddenly went into cardiac arrest. We began resuscitation efforts for over 45 minutes. She was “bleeding out” due to her thin blood The frequency at which lab, culture and significant clinical states is missed is truly alarming.
  6. 6. 14. When I was reviewing for Insurer, I was called by the hospital case manager about a patient whose hospital days were being denied by the Insurer (almost a week worth). The Insurer physician reviewer had even spoken with the patient’s hospital physician to try to get clinical information that would authorize payment. Apparently (and occurs often) the hospital physician did not give the insurer MD clinical information that would authorize payment.. So at the request of the hospital case manager (which usually the case would have gone into claims and never paid or delayed for months), I reviewed the case. Approximately 5 days prior the patient had suffered a cardiac event and her troponin levels (which if elevated means you suffered cardiac damage) were STILL elevated. So I called the Insurer MD myself and let him know of this clinical information and he immediately authorized payment. 15. Many times I reviewed culture results and if I could not find them on the computer or in the chart, I would have to literally knock on the laboratory door to have them look up paper documentation as to whether a patient had any positive cultures. This is especially important when reviewing a patient for a discharge facility because the Health Dept can close them down if they put a patient with a certain infection with an uninfected patient. With some disconcerting frequency, I would find a positive culture that the infectious disease physician had not been informed of. So the patient would have to stay another several days to be treated for the infection and then transferred to a discharge isolation bed. 16. I was called by a case manager from a San Fernando hospital regarding transferring a patient out of the ICU and into a subacute level bed. When I arrived, I spoke with the bedside nurse who told me the patient had over 600 cc of diarrhea in the last 12 hours. I asked the nurse if the physician had been informed of this and she said no. I noticed there were no stool cultures (usually if a patient is having such large volume stools, the physician will want to rule out c. diff). Also, the patients veins were so poor that the nurse had placed an IV in the patient’s foot. This is a precarious location for an IV and more concerning, the patient was a diabetic. Diabetics do not heal well so great care has to be taken with skin integrity. The foot IV could dislodge and/or ulcerate. Using Priority Healthcare medical checklist, I documented the issues and gave a copy to the bedside nurse, the hospital case manager and the physician. The MD put a hold on the patient’s transfer, ordered a c. diff stool culture, reviewed the tube feeding formula (which can cause diarrhea) and ordered a PICC line to be inserted. A PICC IV line is a larger vein, can be left in longer than a regular IV line. Two days later, the issues were resolved and the patient was transferred to a lower cost subacute bed.
  7. 7. 17. Morbidly obese patients are difficult to place in a discharge facility due to the fact that their weight puts a strain on the nursing staff to reposition in bed. Their weight can cause bed sores requiring freq repositioning in bed and wound care. Also, the patient may need to be in a special bed (which is more expensive than a regular bed) to fit their size and to decrease pressure on their skin. Sometimes these patients sit for months in the hospital because the hospital case manager does not know how to problem-solve. So the algorithm for this type of patient is to record weight loss, document mobility with physical therapy notes, place a “trapeze” device to allow the patient to assist the nurse in repositioning, may need plastic surgery consult for severe bed sores or stress to discharge facility that the patient has no wounds, hospital may consider renting a special bed for the patient for 6 months to a year (which is still saving them thousands of dollars to get the patient to a lower cost facility) and sometimes the bed companies will comp a patient bed as a form of marketing to the hospital for perhaps a year. Once these issues are addressed, the patient will be much more “attractive” to a discharge facility. 18. One of Priority Healthcare clients was a subacute (that also had skilled nursing level beds) in Santa Monica. Subacute level patients need to be evaluated carefully as oxygenation and how it is administered are key assessment issues. Skilled nursing patients are much more stable although, they too, should be clinically evaluated prior to transfer out of acute inpatient care. I evaluated a skilled nursing level patient who had just had his tracheostomy plugged and then removed. He was on nasal cannula oxygen and very stable. So I OK”d his transfer to skilled nursing level of care. That same evening I received a panic call from the facility that the patient had deteriorated as soon as he was wheeled into the discharge facility and had to be coded (Code Blue resuscitation) and returned to the hospital. Apparently, just before the patient was discharged from the hospital, he de-compensated and had to re-insert the trach and place an oxygen collar. I was very concerned because the facility should not have accepted the patient with such a drastic change in respiratory status. The hospital staff as well were responsible for the discharging an unstable patient. This type of poor care or discharging inappropriately will increase costs due to re-admissions. This just illustrates how important discharge assessment is. This is another feature of our system, to evaluate clinical discharge states just prior to discharge. 19. While I was evaluating gyn/obstetric surgical patients for an Insurer, I noticed that a fair number of these patients were being re-admitted 5 to 7 days after discharge with small bowel obstructions. The industry standard (Milliman) allows for a 2 day hospital stay for excision of fibroids and hysterectomy. If the patient, on the second or third day was having flatus (meaning gas) which is an early indication of the return of bowel function by industry standards the patient should be discharged. I spoke with the Insurer relaying my observations and that perhaps keeping these patients in 1 more day to make sure the
  8. 8. Continued… patient had a bowel movement (with the aid of stool softeners or laxatives/enema) this would save expensive re-admission and need for bowel surgery. This is another process of our system to evaluate re-admissions and encourage pro-active cost-saving industry changes. . 20. Insurers hire multiple RN case managers, discharge planners, claim processors, physician reviewers, hospitalists and intake center personnel to manage millions of patients nationwide. The hospital hires multiple RN case managers, discharge planners, claim processors, hospitalists and admission department personnel as well. This workforce adds up to billions of dollars a year in replicated, inefficient services. One can liken this process to the 1950’s college fad of piling over 22 people into a phone booth. NO ONE is going to be able to place a phone-call in these cramped conditions. Our system will create job opportunities in IT, Clinical and Medical arenas WHILE improving healthcare service delivery and saving the system trillions of currently wasted dollars. 21. Our government is focusing on placing electronic medical records on-line with a taxpayer funded 30 billion dollars. Of course, easy access to medical records is a useful endeavor but will not resolve the faulty processes of our healthcare system. Physicians, hospitals and insurers already have access to medical records albeit in a sluggish manner. The crux of our healthcare problem IS HOW THE CLINICAL INFORMATION IS MANAGED DAILY on a molecular level. What the government is proposing is like putting icing on a burnt cake. We need to make sure the batter of this cake and how it is baked deserves the effort of icing it. Covering up the REAL issues will only serve to push us further into deficit. At this level of financial disintegration, we need to start watching every penny, every dime, every billion. This takes experience in medicine, clinical processes and knowledge of current flaws on every level. Medrok’s system addresses these core issues and consistently, actively resolves our “bad habit” of wasting pennies, dimes and billions. 22. There are no subacute level dialysis services. The patient either has to be acute long term or skilled nursing level. Otherwise, the patient remains in the hospital for months. We need to CREATE subacute level dialysis facilities in order to decrease cost of such patients. We need to invent protection devices that keep agitated patients from pulling out their airway without restraining them or tying them down. We need to invent electric bed pulleys which reposition the patient saving the nurses from back injuries. We need to use kiosks in hospitals that can be used to educate patients & family members. We need to create less costly integument (skin) products to decrease the millions of dollars spent on decubitis ulcers/wound care, expensive air-beds e.g. fluctuating gel pads, painting the skin with silicone to protect skin from acidic urine and stool. We need a portable home
  9. 9. Continued… health monitoring device which takes blood pressure, heart rate, temperature, blood glucose levels all at once, with this information plugged into the PC for an RN to review daily, in addition to auto-medication administration to monitor medication compliance keeping the patient more stable, out of the hospital, with fewer home health nurse visits.

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