Doctors should treat patients, not insurance company

The doctor wanted to have the patient admitted for observation, yet the patient didn't meet criteria according to the insurance company. Still, the doctor didnt' feel comfortable sending the patient home.

So, what he did was write on the chart, "Recommended patient be kept for observation for best interest of patient."

That way, he said to me, the insurance company is liable if something happens to that patient and now the doctor. He also wrote on the chart, "Patient was sent home against my better judgement."

This is a perfect example of how cook book medicine does not work, and how doctors and nurses should be able to do what's best for the patient, and money should not be a factor.

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Doctors should treat patients, not insurance company

The doctor wanted to have the patient admitted for observation, yet the patient didn't meet criteria according to the insurance company. Still, the doctor didnt' feel comfortable sending the patient home.

So, what he did was write on the chart, "Recommended patient be kept for observation for best interest of patient."

That way, he said to me, the insurance company is liable if something happens to that patient and now the doctor. He also wrote on the chart, "Patient was sent home against my better judgement."

This is a perfect example of how cook book medicine does not work, and how doctors and nurses should be able to do what's best for the patient, and money should not be a factor.

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What are order sets?

Due to the Keystone Collaborative of Michigan, Michigan hospitals are now the envy of the nation, and have even caught the eye of President Obama. One of the key features of the commission is to encourage hospitals to install order sets for each particular diagnosis (DRG).

In the past order sets were rejected by doctors mainly because they viewed order sets as cook book medicine. So, what is cook book medicine?

Cook Book Medicine: Treating all patients with a given DRG the same way.

Obviously this wasn't thought to be a good idea. While the main goal of the commission is to help hospitals improve patient outcomes and reduce costs, I believe the main goal is to make sure a patient meets the criteria for receiving a reimbursement check from the Centers for Medicare and Medicaid Services (CMS).

As you know, CMS has set standards for minimal care they will reimburse for. It doesn't come down to the personal opinion of the doctor treating each patient according to what is best for the patient. What it comes down to is the fact CMS decided in order to reduce it's cost (not the hospital's cost), it will only reimburse if it's own reimbursement criteria is met (see this post).

Thus, if order sets were to the benefit of the patient, they would have been enacted many moons ago. The truth is, order sets were never enacted until CMS increased it's standards on what patients will meet criteria for reimbursement.

So based on Keystone Recommendations, many hospitals in Michigan have adopted Order sets. So what is an order set?

Order sets: This is a sheet of paper a nurse pulls from a drawer that has on it all the procedures that are recommended for that particular diagnosis. It pretty much lists anything a doctor might want to order, plus anything CMS might recommend for that patient to meet criteria for reimbursement (this is key). This type of order set would be ideal because it simply acts as a reminder of what the doctor might want to order to help the patient.

Pre-checked order sets: Many of the boxes on order sets at many hospitals are pre-checked. This means they are ordered automatically and are mandatory whether the doctor thinks they are needed or not. Due to government criteria, many hospitals have had no choice but to resort to doing this.

Advantages of order sets:

• Puts the doctor, nurses and all other staff (including RT) on the same page
• Assures best practice medicine is met for this patient
• Makes sure doctors don't forget to order what is recommended or needed
• Allows hospital to modify care based on evidence based practice
• Increases organization so you know what will be ordered for a patient
• Everyone knows their role in regards to that patient

Disadvantages of order sets (unintended consequences):

• Treating all patients the same
• Decreases doctor autonomy
• Decreases incentive to think outside the box (critical thinking)
• Many unnecessary orders
• Causes burnout due to too many procedures
• Causes apathy due to burnout and lack of ability (or lack of time) to do critical thinking

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What are order sets?

Due to the Keystone Collaborative of Michigan, Michigan hospitals are now the envy of the nation, and have even caught the eye of President Obama. One of the key features of the commission is to encourage hospitals to install order sets for each particular diagnosis (DRG).

In the past order sets were rejected by doctors mainly because they viewed order sets as cook book medicine. So, what is cook book medicine?

Cook Book Medicine: Treating all patients with a given DRG the same way.

Obviously this wasn't thought to be a good idea. While the main goal of the commission is to help hospitals improve patient outcomes and reduce costs, I believe the main goal is to make sure a patient meets the criteria for receiving a reimbursement check from the Centers for Medicare and Medicaid Services (CMS).

As you know, CMS has set standards for minimal care they will reimburse for. It doesn't come down to the personal opinion of the doctor treating each patient according to what is best for the patient. What it comes down to is the fact CMS decided in order to reduce it's cost (not the hospital's cost), it will only reimburse if it's own reimbursement criteria is met (see this post).

Thus, if order sets were to the benefit of the patient, they would have been enacted many moons ago. The truth is, order sets were never enacted until CMS increased it's standards on what patients will meet criteria for reimbursement.

So based on Keystone Recommendations, many hospitals in Michigan have adopted Order sets. So what is an order set?

Order sets: This is a sheet of paper a nurse pulls from a drawer that has on it all the procedures that are recommended for that particular diagnosis. It pretty much lists anything a doctor might want to order, plus anything CMS might recommend for that patient to meet criteria for reimbursement (this is key). This type of order set would be ideal because it simply acts as a reminder of what the doctor might want to order to help the patient.

Pre-checked order sets: Many of the boxes on order sets at many hospitals are pre-checked. This means they are ordered automatically and are mandatory whether the doctor thinks they are needed or not. Due to government criteria, many hospitals have had no choice but to resort to doing this.

Advantages of order sets:

• Puts the doctor, nurses and all other staff (including RT) on the same page
• Assures best practice medicine is met for this patient
• Makes sure doctors don't forget to order what is recommended or needed
• Allows hospital to modify care based on evidence based practice
• Increases organization so you know what will be ordered for a patient
• Everyone knows their role in regards to that patient

Disadvantages of order sets (unintended consequences):

• Treating all patients the same
• Decreases doctor autonomy
• Decreases incentive to think outside the box (critical thinking)
• Many unnecessary orders
• Causes burnout due to too many procedures
• Causes apathy due to burnout and lack of ability (or lack of time) to do critical thinking

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Order sets are stupid, IMO

Based on my experience as a departmental representative at various administrative committees, I am privy to some wisdom not available to the general public. For instance, many hospitals have order sets that are hidden under the guise as protocols.

No, they are not protocols. Protocols increase personal accountability and responsibility. Protocols increase personal thought and intellectuality. Protocols preach individuality.

Yet order sets, while started with the intention of doing what is best by best practice medicine, generally make it so each patient is treated the same. Order sets take away personal accountability, individual thought, personal accountability and responsibility.

Protocols improve morale, and order set decrease morale. Order sets decrease morale because all we do is a bunch of procedures not because they are needed, or even because a doctor wanted them, but just because. Order sets are cook book medicine.

Order sets (which, again, go under the guise as protocols and guidelines) not only result in decreased morale, they increase the cost of medicine because, ahem, someone has to pay for all of this impractical medicine.

CMS only pays a flat fee (because of DRGs), and those obtaining CMS services get free healthcare (well, free to them anyway. We have to pay for their free). Therefore, the one's who will pay are those of us who pay premiums for health insurance.

We will pay more. This goes along with the premium hikes we will now have to pay because Obama care provisions to force insurance companies to pay for dependents until they are 25, and previous medical conditions (liabilities).

Consider the following:

1. Of the 20 EKGs I did today, only 15 were needed. All were ordered not by a doctor but by an order set.

2. Of the five ABGs I did today, none were needed. All were ordered not by a doctor but by an order set.

3. Of the 30 breathing treatments I did today 28 were not needed. All 28 were ordered not by a doctor but by an order set.

4. Of the six stress tests completed in my department today, none were needed. All were ordered as a result of an order set.

Order sets wouldn't be so bad in and of themselves, but most of the items on them are pre-checked, at least at my institution. To not order something, the doctor has to scratch out the item and sign. And then risk a lecture by the Quality Review lady. So it's easier for them not to bother.

If order sets were as they were initially intended, a list of all possible procedures the doctor might want to order, then order sets wouldn't be so bad. And balanced by good protocols to eliminate ordered procedures that aren't needed, order sets would also be good.  Yet that's not how it is when you resign yours institution to cook book medicine.

Thus, most items on order sets are ordered whether needed or not. Common sense is not the result of an order set. Common sense and individual thought are down the drain.

The following are unintended consequences of order sets:

• Lots of not needed procedures
• Wasted money
• Increased workload for RTs
• Increased burnout
• Loss of confidence due to loss of ability to decide what patients need
• Loss of morale due to inability to use common sense
• Poor attitude at bedside because after the umpteenth not needed EKG or treatment you get irritated by it all. It becomes a job rather than a profession, like working an assembly line at a factory
• Poor patient care due to low morale and in a hurry to get all the procedures done
• Feeling of irritation by RTs because we're doing a bunch of BS
• Increased apathy
• RTs develop RATS, which isn't good for the institution (and I'm not talking about the creepy little critters either.)

In the ideal world order sets are counterbalanced by protocols.  But in the real world idealism in merely a pipe dream. 

Yes, there are some advantages to order sets. Yet the disadvantages are way more than the advantages. There's an old saying: Something is worth the investment only when the advantages out weight the disadvantages.

And in this case, the few recommending these order sets (mainly people sitting at a desk in Lansing or Washington) have a clue of the negative consequences. Or do they? Perhaps the intent is to collapse the health care system. Perhaps that's the intent. If it's not, I have a hard time justifying it.

Thoughts?

read more...

Order sets are stupid, IMO

Based on my experience as a departmental representative at various administrative committees, I am privy to some wisdom not available to the general public. For instance, many hospitals have order sets that are hidden under the guise as protocols.

No, they are not protocols. Protocols increase personal accountability and responsibility. Protocols increase personal thought and intellectuality. Protocols preach individuality.

Yet order sets, while started with the intention of doing what is best by best practice medicine, generally make it so each patient is treated the same. Order sets take away personal accountability, individual thought, personal accountability and responsibility.

Protocols improve morale, and order set decrease morale. Order sets decrease morale because all we do is a bunch of procedures not because they are needed, or even because a doctor wanted them, but just because. Order sets are cook book medicine.

Order sets (which, again, go under the guise as protocols and guidelines) not only result in decreased morale, they increase the cost of medicine because, ahem, someone has to pay for all of this impractical medicine.

CMS only pays a flat fee (because of DRGs), and those obtaining CMS services get free healthcare (well, free to them anyway. We have to pay for their free). Therefore, the one's who will pay are those of us who pay premiums for health insurance.

We will pay more. This goes along with the premium hikes we will now have to pay because Obama care provisions to force insurance companies to pay for dependents until they are 25, and previous medical conditions (liabilities).

Consider the following:

1. Of the 20 EKGs I did today, only 15 were needed. All were ordered not by a doctor but by an order set.

2. Of the five ABGs I did today, none were needed. All were ordered not by a doctor but by an order set.

3. Of the 30 breathing treatments I did today 28 were not needed. All 28 were ordered not by a doctor but by an order set.

4. Of the six stress tests completed in my department today, none were needed. All were ordered as a result of an order set.

Order sets wouldn't be so bad in and of themselves, but most of the items on them are pre-checked, at least at my institution. To not order something, the doctor has to scratch out the item and sign. And then risk a lecture by the Quality Review lady. So it's easier for them not to bother.

If order sets were as they were initially intended, a list of all possible procedures the doctor might want to order, then order sets wouldn't be so bad. And balanced by good protocols to eliminate ordered procedures that aren't needed, order sets would also be good.  Yet that's not how it is when you resign yours institution to cook book medicine.

Thus, most items on order sets are ordered whether needed or not. Common sense is not the result of an order set. Common sense and individual thought are down the drain.

The following are unintended consequences of order sets:

• Lots of not needed procedures
• Wasted money
• Increased workload for RTs
• Increased burnout
• Loss of confidence due to loss of ability to decide what patients need
• Loss of morale due to inability to use common sense
• Poor attitude at bedside because after the umpteenth not needed EKG or treatment you get irritated by it all. It becomes a job rather than a profession, like working an assembly line at a factory
• Poor patient care due to low morale and in a hurry to get all the procedures done
• Feeling of irritation by RTs because we're doing a bunch of BS
• Increased apathy
• RTs develop RATS, which isn't good for the institution (and I'm not talking about the creepy little critters either.)

In the ideal world order sets are counterbalanced by protocols.  But in the real world idealism in merely a pipe dream. 

Yes, there are some advantages to order sets. Yet the disadvantages are way more than the advantages. There's an old saying: Something is worth the investment only when the advantages out weight the disadvantages.

And in this case, the few recommending these order sets (mainly people sitting at a desk in Lansing or Washington) have a clue of the negative consequences. Or do they? Perhaps the intent is to collapse the health care system. Perhaps that's the intent. If it's not, I have a hard time justifying it.

Thoughts?

read more...