The system is broken, example #4728262

[Celexa]

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Part of my academic gig involves an embedded clinic with a medical subspecialist. I love this work--by working side by side with my medical colleague (often seeing the patients together) I can address issues that are very hard to get to in separate clinics.

But here's one real annoying thing. Epic won't let us schedule the same patient on both of our scheudles at the same time.

You know what IS possible? Double or even triple booking patients on an individual schedule.

So the physically impossible thing (one person being in two or three rooms simultaneously) can be booked, but two doctors seeing one patient together is anathema.

We find workarounds but what a perfect encapsulation of the fragmentation and absurdity of the American healthcare system

 

[clozareal]

Sounds more like an Epic problem at your academic location. We were able to do this where I went to medical school as subspecialists often popped in to see patients at the same time as the other medical specialties all the time.

 

[Celexa]

Sounds more like an Epic problem at your academic location. We were able to do this where I went to medical school as subspecialists often popped in to see patients at the same time as the other medical specialties all the time.

Entirely possible, which means I can eventually probably straighten it out within 2-3 IT ticket submission attempts to get to someone who understands what we're asking for and another several layers of hand offs and buck passing to figure out who actually can fix it, and then whether it's their job to fix it....

Which really all boils down to the same thing in the end, which is that doing things well is always harder than it should be....

 

[tr]

This is a feature, not a bug.
Epic is designed to maximize billing/collections.
Two docs can't both bill for one encounter. Therefore Epic ensures this cannot be scheduled.

 

[splik]

Things are less broken than it was. I remember as a resident working in an HIV clinic and back then only one visit was billable on the same day so if patients had a psych and ID visit on the same day (at different times) only one was paid for. That's no longer the case. When I was in academics, I did sometimes see pts jointly w/ neuro and we were able to schedule at the same time. But you wouldn't be able to bill for both (double dipping) so it wasn't common.

What you're describing is that your institution is broken, and yet you externalize onto some amorphous non-existent "system". If they wanted to they could develop a innovative value based way of being compensated for such care.

 

[Celexa]

Things are less broken than it was. I remember as a resident working in an HIV clinic and back then only one visit was billable on the same day so if patients had a psych and ID visit on the same day (at different times) only one was paid for. That's no longer the case. When I was in academics, I did sometimes see pts jointly w/ neuro and we were able to schedule at the same time. But you wouldn't be able to bill for both (double dipping) so it wasn't common.

What you're describing is that your institution is broken, and yet you externalize onto some amorphous non-existent "system". If they wanted to they could develop a innovative value based way of being compensated for such care.

So both of us are actually billing via separate encounters. It's currently unclear to me whether my individual billing will cover my salary--the partnering department understands that they will be eating the difference. It's just darkly funny to me how hard it is to make a functioning clinic in small, unnecessary ways. I definitely recognize the various overlapping and non overlapping motivations in leadership (or it's absence) which drives a lot.

I was a pgy2 when Covid rolled through, so it's harder for me to speak to the precovid world, but it does seem like maybe more energy is getting drained off into crises. I've heard of a lot of places, ours included, where crises on inpatient ties up a lot of leadership resources and anywhere not actively on fire languishes. The severe degree to which this is the case seems Covid related to me, but maybe it's just how things have always been.

 

[smalltownpsych]

So both of us are actually billing via separate encounters. It's currently unclear to me whether my individual billing will cover my salary--the partnering department understands that they will be eating the difference. It's just darkly funny to me how hard it is to make a functioning clinic in small, unnecessary ways. I definitely recognize the various overlapping and non overlapping motivations in leadership (or it's absence) which drives a lot.

I was a pgy2 when Covid rolled through, so it's harder for me to speak to the precovid world, but it does seem like maybe more energy is getting drained off into crises. I've heard of a lot of places, ours included, where crises on inpatient ties up a lot of leadership resources and anywhere not actively on fire languishes. The severe degree to which this is the case seems Covid related to me, but maybe it's just how things have always been.

I’ve worked in a lot of places that are always in crisis mode. Pre-Covid as well. I am not a big fan of crises so I tend to do whatever I can to avoid them, others not so much. For some, the crisis becomes an excuse or deflection from not being that good at their jobs or having other problems such as chronic lateness or excessive absences because of their excessive etoh use. Have seen that play out a time or two.

 

[clausewitz2]

Since this is a thread for systemic idiocy, here's one:

So I am partially in PP and partially work for an agency. In my agency work I happen to have a fair number of patients on clozapine. We had been having problems with accessing CBC results in a timely fashion, which is obviously an enormous problem for clozapine due to REMS requirements. Our patients were getting bloodwork done but our agency seemed just utterly incapable of receiving faxes from labs and passing them along to us until many months later, if at all. So I hit upon the idea of using the account I have with Quest for my PP to input orders and see results, which immediately solved the problem and worked brilliantly. Six month delay turned into me getting the numbers a couple days later. Worked great for about two years.

Then there is a shakeup in our team and the agency decides we need a compliance officer. They get wind of the fact that we are getting lab results from anything other than the agency fax number and immediately flag this. We are told that we can only order labs on official agency paper lab slips and any other form of ordering this is unacceptable. We go from having extremely high compliance with monitoring guidelines for all kinds of medication to basically never having any labwork results for anyone in a timeframe that would be relevant. Medical director himself personally emailed me to insist that only agency lab slips were acceptable, even when I offered to personally print out and scan into our EMR every single lab result from Quest.

I of course document in my note every time this happens that I provided lab orders on paper slip and did not receive results because this is on them. My clozapine patients are doing okay because before I got this mandate I had sent standing orders to Quest good for a year for regular CBCs. I am genuinely unsure what I am going to do when those expire. At the end of the day I will do whatever is necessary and let's see them try to discipline me for taking steps to follow legal monitoring guidelines, but part of me still feels there must be some misunderstanding. But no, it's in black and white, they would rather have patients not able to receive clozapine (some of whom are poster children for clozaril, the sort who spend months hospitalized off of it but on it hold full-time jobs) than god forbid there be something slightly out of policy in how they receive lab results.

I just wonder how as a psychiatrist the medical director got to the point where he could say this kind of thing with a straight face and apparently feel utterly righteous in doing so.

 

[smalltownpsych]

Since this is a thread for systemic idiocy, here's one:

So I am partially in PP and partially work for an agency. In my agency work I happen to have a fair number of patients on clozapine. We had been having problems with accessing CBC results in a timely fashion, which is obviously an enormous problem for clozapine due to REMS requirements. Our patients were getting bloodwork done but our agency seemed just utterly incapable of receiving faxes from labs and passing them along to us until many months later, if at all. So I hit upon the idea of using the account I have with Quest for my PP to input orders and see results, which immediately solved the problem and worked brilliantly. Six month delay turned into me getting the numbers a couple days later. Worked great for about two years.

Then there is a shakeup in our team and the agency decides we need a compliance officer. They get wind of the fact that we are getting lab results from anything other than the agency fax number and immediately flag this. We are told that we can only order labs on official agency paper lab slips and any other form of ordering this is unacceptable. We go from having extremely high compliance with monitoring guidelines for all kinds of medication to basically never having any labwork results for anyone in a timeframe that would be relevant. Medical director himself personally emailed me to insist that only agency lab slips were acceptable, even when I offered to personally print out and scan into our EMR every single lab result from Quest.

I of course document in my note every time this happens that I provided lab orders on paper slip and did not receive results because this is on them. My clozapine patients are doing okay because before I got this mandate I had sent standing orders to Quest good for a year for regular CBCs. I am genuinely unsure what I am going to do when those expire. At the end of the day I will do whatever is necessary and let's see them try to discipline me for taking steps to follow legal monitoring guidelines, but part of me still feels there must be some misunderstanding. But no, it's in black and white, they would rather have patients not able to receive clozapine (some of whom are poster children for clozaril, the sort who spend months hospitalized off of it but on it hold full-time jobs) than god forbid there be something slightly out of policy in how they receive lab results.

I just wonder how as a psychiatrist the medical director got to the point where he could say this kind of thing with a straight face and apparently feel utterly righteous in doing so.

I am glad you found a way to help ease the process for clozapine for your patients and sad that bureaucracy found a way to stop it. It is hard enough for my patients to get their prescriptions filled regularly because of paperwork snafus and with the clozaril stuff it just adds another layer. Between the caseworker, the patient, the psychiatrist, the psychiatrist staff, the pharmacy, and the labs there is a lot of potential for issues. Good thing my patients that need clozaril are so organized and logical and good at navigating complex broken systems. 😉

 

[milesed]

Our 2 local medical hospitals use Epic and sifting through their records is such a pain.

 

[TheRightMedication]

Clausewitz,

Good on you for getting the labs done. I'm surprised at your hesitancy to carry on with Quest labs, though. If you've documented the delays that put the clinic outside of the standard of care, I feel like you're on rock solid ground. What are they going to do, fire you?

Alternatively if you feel like the clinic is forcing you to practice outside the standard of care, maybe it's time to quit. I bet there's language in your contract that would make that a breach on their part. Maybe you can quit today.

 

[clausewitz2]

Clausewitz,

Good on you for getting the labs done. I'm surprised at your hesitancy to carry on with Quest labs, though. If you've documented the delays that put the clinic outside of the standard of care, I feel like you're on rock solid ground. What are they going to do, fire you?

Alternatively if you feel like the clinic is forcing you to practice outside the standard of care, maybe it's time to quit. I bet there's language in your contract that would make that a breach on their part. Maybe you can quit today.

I think I am going to take it up with the medical director again at the end of the year when a significant fraction of my caseload blows past standard monitoring guidelines despite my best efforts at handing pieces of paper to people who I often see via tele. There are also questions of model adherence at the state level for this particular clinic that could cause major headaches for them and endanger special funding streams, so I do have that leverage at least. heck, we actually have monthly supervision meetings with some of the state level folks involved with coordinating this area, I should bring it up as a question I am seeking their advice on and see what happens.

I really don't want to quit because I love the work and it's a great gig in most respects, but yeah if I quit today I'd have the hours filled with PP patients completely by the end of the month so the downsides are minimal.