Jul-Aug 2001 Table of Contents

PRACTICE DIARY

Chapter 27



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Fam Pract Manag. 2001 Jul-Aug;8(7):48-49.

Panic attack

A recent letter from my electronic billing clearinghouse had me in a tizzy:

“Dear Valued Customer,” it read, “As a health care provider, you are no doubt aware of the many changes taking place not only in our industry but in technology as well. Our commitment to you requires us to keep pace with these changes. … Some changes, however, such as the new regulatory mandates established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), affect our ability to support existing products and services. … After careful consideration of such issues … we are preparing to discontinue support of the Claims Management system effective July 31, 2001.”

The Claims Management system is the clearinghouse’s computer platform to which I submit my claims electronically, so their letter had me worried. It went on to talk about software upgrades that providers would have to make to their office management systems in order to transmit claims to the new platform, but it also mentioned that my current software conformed to the new transmission requirements. What did it all mean? Did I really have to upgrade my program just to stay online for electronic claims? The idea made my palms sweat. It would mean having to learn a new, more complicated version of my office management software and having to buy all new computer hardware to run it to boot. Nightmarish thoughts of error messages when attempting file transfers, incompatible backup systems and data-entry snafus flooded my mind. I knew HIPAA spelled trouble when I first heard about it, and here it was, a full two years before it was due to be implemented, already threatening to suck out my economic lifeblood.

“Isabel,” I said to my office manager, “Get me the clearinghouse. This is an emergency!”

Their rep told me to call my software vendor, but when I called them they said they hadn’t heard about the letter. “Fax it to me,” Brandon, the software rep, said, “and I’ll get back to you.”

Several hours later, he did – with good news: “It’s just a matter of completing some paperwork. Your program will work. Give me your fax number and I’ll send you the forms to fill out. Mail them back to me and I’ll take care of it,” he said.

Suddenly, my appetite returned. I was able to concentrate on my work. I relaxed. I smiled. “Isabel,” I said. “Life is good.”

Medical records

I was awakened at midnight by a call from the emergency room. Howard, an elderly patient of mine, had come in by ambulance after suffering a syncopal episode at home, falling and fracturing four ribs. He was otherwise all right and had a negative work-up. The ER doc just wanted to let me know what had happened and arrange for follow-up before sending him home. “By the way,” I said, “Howard’s done this before.”

“I know,” she said. “He told me it was about six months ago.”

“Was the work-up similar?” I asked.

Sheepishly, she admitted she hadn’t been able to view the old record. Since the hospital recently scanned all medical records onto computer disks with a non-user-friendly interface, many of the doctors were helpless in accessing them. “Laura, is the system broken or do you not know how to use it?” I asked.

She confessed she was uncomfortable with computers and mourned the loss of the paper record. When time permitted, some ER docs had the clerks print out the record for them, which was a slow, laborious process at best, but mostly they winged it.

I remembered from my internship days how the most important information you could have on a patient was his or her old records. History repeats itself, and in treating patients with chronic ailments, it isn’t necessary to reinvent the wheel. Data is everything. I can’t count the number of times I’ve gotten out of trouble by reading old charts.

In this electronic age, we tend to forget how many physicians are computer-phobic or computer-illiterate. A physician not having access to patients’ records is like a mechanic not having access to the shop manual.

“Laura,” I offered, “let’s get together soon and see if we can’t figure out how to get the information you need out of the computer.”

“Fine,” she replied, “I’d really like that.”

Saying no

I hate turning down prospective patients when they ask me to be their family physician, but sometimes the relationship just doesn’t feel right. Better to be honest up front, I figure, than to allow both of us to suffer from a mismatched relationship.

Yesterday, a 58-year-old woman with multiple sclerosis appeared with her husband for a consultation. She used a cane but was otherwise ambulatory and seemed to have no other obvious disabilities. Her only complaint was a severe stabbing sensation in both legs for which one doctor had put her on fentanyl patches with Dilaudid for breakthrough pain. As we talked, it became apparent to me that her MS was relatively stable; she had pain-management problems.

I shy away from long-term prescribing of opiates for any patient because they are addictive and can often do more harm than good, and I had to beg off. Her dilemma, she said, was that she needed a primary care doctor to refer her to specialists, but when I offered to make the referral to a pain clinic, she balked because of the distance and expense. I surmised she just wanted me to continue her prescriptions. Was she truly in distress, or was she conning me? “I’m sorry,” I said, “but I don’t do pain management except for terminal care patients.” She became teary. “I do wish I could be of more help, but that’s not what I feel comfortable doing,” I concluded. I gave her some other physicians’ phone numbers, she left and I didn’t charge them for the visit.

"No, doctor. I'm not suggesting you were confused about your coding. It's just curious that your ICD-9 codes match your patient's Zip codes."

Dr. Brown, a solo family physician living in Mendocino, Calif., is a contributing editor to Family Practice Management. These excerpts from his journal illustrate the many characters, stories and lessons family practice has to offer. No real patient names have been used. Conflicts of interest: none reported.

Copyright © 2001 by the American Academy of Family Physicians.
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