I am a member of a large primary care group certified as a level 3 patient-centered medical home; we are in the midst of certifying for Meaningful Use Stage 2. Recently, my first patient of the day was a 65-year-old widowed man who used tobacco, had diabetes, hypertension, and elevated lipid levels, and hadn’t seen me in 2 years. He came in for a Medicare Advantage comprehensive physical examination.
To meet all Meaningful Use Stage 2 expectations during his physical exam, I had to:
• check the box to document discussion of body mass index (his was 26 kg/m2),
• check the box for functional status assessment,
• check the box to indicate that his blood pressure was under 140/90 mm Hg (the threshold for a previously diagnosed hypertensive patient),
• generate annual care guides for the “clinically important conditions” of hypertension with diabetes, tobacco use, and hyperlipidemia,
• review the quality information stoplight for lab tests to be ordered,
• remind the patient to complete his annual eye examination,
• identify hierarchical categorical coding to maximize the accurate morbidity determination of my patient and, therefore, funding for our medical group,
• click on the code for annual prostate examination screening,
• click on the code to bill for tobacco cessation counseling, and
• generate a visit summary.
Naturally, all of this was in addition to giving my patient my full, undivided attention, providing him with the opportunity to express his concerns, and then pursuing a careful examination of his health problems.
Documentation expectations, coding, billing, and the like degrade the clinician-patient relationship, and I’m not going to redirect my attention away from the patient’s concerns and toward these activities. I will continue to listen and respect what my patients have to say and engage with them, and not my keyboard. I will strive to identify and meet their health needs.
Click the boxes? Yes, I will click all the right boxes; my livelihood and my medical group’s future success depend on that. But how much congruence will there be between what I “click” and what I “do”? Well …
We are challenged by good intentions but crushingly poor execution—and it’s taking its toll.
H. Andrew Selinger, MD