Friday, May 27, 2011

A Head Code? A Cardiac Code? A Trauma Code? A Human Code?

A principle impediment to effective modern medical practice is our ever increasing addiction to ‘coded data.’

During my own medical informatics training my mentors extolled the virtue of ‘coded data’ and promised a utopian practice when all parts of the medical encounter were based on the hard ‘coding’ of clinical data.

Certainly compared to back then (1997), we have made enormous leaps in taking the stubborn clinical encounter and transforming it into an industrial process complete with abundantly coded clinical data elements. The engine for this transformation has been the payor’s demands for validation of services and medical necessity. Through the insistence of those that pay of the bills all structured, disciplined, reasoned, and principled resistance to ‘hard coding’ of our patient’s has collapsed and the coding is ongoing at an ever accelerating rate.

Somehow in this process we believe, wrongly in my view, that  we have insight into the patient and the patient’s problems. However, I feel this highly unlikely. Having used various electronic medical record systems since the 1980’s, I find for my own part that I am not edified or enlightened by reviewing the list of ‘coded’ diagnoses that are so popular in EMR systems.

In my own practice, at various times, places, and venues I have and do function as a Hospitalist, Internist, Cardiologist, Critical Care Physician, and Emergency Medicine physician. This is a relatively wide set of clinical roles for one physician, but as Winston Churchill was found of saying, ‘a change is as good as a rest.’

All these roles see the patient encounter and the patient through various different prisms. And it has bothered me greatly over the years, with respect to the EM (Evaluation and Management) codes that we are supposed to define our patient encounters along a continuum of interest that deals with ‘simple problems’ to complex problems. And a central purpose of the modern EMR is to help us elucidate the complexity of our clinical actions in a method akin to that of the old vaudeville joke in which you order a Chinese meal by getting ‘one from column A and one from column B.’

Let me make the heretical assertion, there are no ‘simple’ clinical problems and no simple clinical encounters, there are are only simple minded practitioners. Let me provide for you an example which illustrates this principle... I had in the past, seen a simple sore throat, which was seen several hours earlier by a colleague. The mother brought the child for re-evaluation within 6 hours of the first evaluation, risking the ire of the ER staff, because the baby had not yet improved.

I know for those of you who work in Emergency Departments, you can readily hear in the background of your minds eye (forgive the mixed metaphor) that droning Greek chorus of staff voices, decrying the stupidity of the mother for re-evaluation, after all, she just barely picked up the antibiotic and had just barely given the child the first dose.

I entered the room, and found a two month old waif of a child, appearing desperately ill, ice-pale in color, listless and uninvolved in her surroundings. Her abundant and easily palpable lymphadenopathy had the quality and feel of large shooter marbles, locked and immobile in the soft tissues of her neck. Terrifying to find and terrifying to feel. The lymphocyte count astronomical, the platelet count nearly undetectable, she was induced that evening for treatment of her acute lymphocytic leukemia.

I am sure that the time I spent with the child was not much less than that spent by my colleague earlier that day, but my encounter was complex, his was simple. Or was my encounter also simple? And was I guilty of ‘up coding.’ It was the same patient, the same problem, the same exam, the same day. What gives here, should the payor have to pay for the encounter twice? Should they disallow (or did they disallow - I don’t know) the charges for my visit? The widget (the patient) had been processed once that day, why pay for a second look?

In fact, the case illustrates some profound truths about the central depravity of ‘coding.’ I am, you are, any practitioner is paid just as handsomely or poorly as befits your perspective, for being wrong as for being right. Furthermore, as you probably can imagine from your own practice, being wrong is generally more profitable and more expedient and expeditious than being right.

This thought and realization drives me middlingly crazy, that I would be paid as much for being wrong (something that usually takes very little time) as I am for being right. Since being right will take a real history accomplished in partnership with a real human who is generally unaccustomed to medical technical lingo, and a careful and thoughtful physical examination. But so perverted are the incentives in medical care, that to do a careful, systematic, and thorough job of clinical evaluation, prior to the laboratory panels, or imaging studies, dooms yourself to business extinction.

Here is a useful model of medical work....



It is my own extensions to and representation of the classical bio-psycho-social model of medicine. It is the closest thing to which I can profess to believe in with religious intensity. And within that rich gruel-like milieu of my patient and his/her symptoms, lies the interlocking components and interactions of biological (dys)function, psychological (mal)adaptation, social context, spiritual and existential meaning... all swimming in the sea of his/her culture. What is it about this contextually rich, experientially diverse, and philosophically complex phenomena, the patient;  that allows for some to see a ‘simple problem’ definable and solvable in 15 minutes?

I once calculated (forget the methodology) that I have had perhaps 60,000 plus unique patient encounters, God help me if I ever saw any one of them as anything other than what Churchill so eloquently described, “ A Riddle, Wrapped In A Mystery, Inside an Enigma.’ Left to my lifetime, any one of them could have taken my lifetime to describe and to understand.

But the practicalities are we do the best we can not having a life time to study the one. But, let us please stop for a moment and contemplate in full Shakespearean depth and profundity the glory of each individuals life, the uniqueness of their illness and ultimately the loneliness of their passing.

It is in what I call privately the Maimonidesian dimension of medical practice that I struggle to stay focused when being forced to live in a world of clinically based economic ‘reality.‘ For it is the most human part of the practice of medicine to uniformly recall in all ‘patient encounters’ that ultimately the patient is ‘a fellow creature in pain.’  

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