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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Wednesday, February 09, 2022

Pacemakers generate electricity and tons of data , who monitors the data

 Recently I had my pacemaker replaced.This process is often erroneously refered to as  getting a new battery when in fact it is replacement of the IPG (implantable pulse generator). The IPG consists of the battery,the software  and connectors to the leads. The process takes about 1 to 2 hours and generally the recovery process is quicker than the implantation itself of the pacemaker as arm movement does not have to be as restricted.

Typically, every three months a "remote interrogation" is done. Data is downloaded from the pacemaker and then transmitted to in my case to the Medtronic computer  system and from there to either my physicians office or again in my case to  a third party organization who  then sends an interpretation of the data to my doctor's office.It appears that both the third party company and my EP doc's office can earn a fee approved by Medicare for the report review.

The third party interrogation monitoring company typically sends me a copy by secure Google email of the interrogation. For several reasons which I have written about before I find it important to actually  see my report as opposed to receive a message that " every thing is OK" Or " if you don't here from us everything is OK". The Cures Act now mandates that physicians and hospitals must give the patients copies of lab work and even clinical notes in  a "timely" manner or face hefty fines. Patients no longer have to accept the " we will call if something is not OK" from their doctor. 

The reports themselves are not that difficult to understand as least in regard to a pacemaker versus a ICD (defibrillator). some of the important values to review are: capture voltage,lead impedence ( resistance,)arrhythmias and battery life estimation. The pertinent data can be reviewed quickly .

While the basic data seem to be  well monitored I am less sanguine about the regular occurrence of a review of the  optimal settings for such things as pulse amplitude and pulse duration  and review of arrhythmias flagged by the unit's algorithms. In my case my interrogation report indicated several episodes of AF (atrial fibrillation). This finding lead to a fair amount of concern about having runs of AF but I learned later that the  unit's algorithm misidentified  "far field sensing" as AF. Far field sensing refers to the atrial lead sensing activity from the ventricular lead and double counting of atrial signals. 



Tuesday, February 08, 2022

Phantom physical exam reports continue to proliferate in the strange world of the electronic health record

 Recently,I learned that nurse practitioners as well as physicians are authorized to post  the results of physical exams that were not done in the medical record (EHR) 

The narrative of the encounter  I had with NP was accurate and fairly detailed and I actually learned a lot about how the thousands of remote device interrogation are reviewed in their department.

 Although one of the reasons for the visit was to check the surgical wound (I had a pacemaker replacement one week before) there was no mention of that in the EHR although the NP did glance at the surgical site.  I was described as having no edema and having normal pulses but those findings were fictional. A similar fictional physical exam was detailed in the pre op visit one week earlier with the EP cardiologist. (Actually I do have a trace of ankle edema a the end of the day and my posterior tibial artery is very hard to palpate.)

When I attended medical school in an earlier century my teachers emphasized the importance of transcribing a physical exam and other clinical findings as accurately as possible and that the medical record was a legal record and could be subpoenaed. The medical record is the basic legal document in medical malpractice litigation. 

Why would a bogus physical exam description be routinely inserted into the EHR as that occurrence appears to be the case. If it is done to be able to "upcode" the record why would the practice not be fraud?

Other than an intent to defraud, what else could explain the profusion of bogus system reviews and physical exams. Simply put it may be a unintended consequence of the EHR and the quality movement, Standard boiler plate material is generated by the EHR to fill the need to comply with the increased demand for documentation of "quality "clinical work. The alleged intent was to have clinicians edit out activities not performed.However,that has not been the outcome as through inattention or in some cases perhaps intent the fictitious exams remain displayed in medical records awaiting a plaintiff lawyer to ask Dr. Did you perform a physical exam on a certain date?


addendum: 3-15-2022 I learned from someone knowable in current Medicare charges and EHR vagaries that Medicare no longer pays more if a physical exam is performed and charges are earned based on time spent and case complexity. So there would be no monetary advantage to charting a physical exam or system review but the phantom exams seem to still be appearing in EHRs.