All or Nothing

The other day, as I was wrapping up my visit with Mrs. Brown, she said:

“Harry is no better, he is coughing and spitting something wicked.”

Her husband, silent during the visit, was unshaven and looked a little tired.

“How long have you been sick?” I turned to him.

“Going on two weeks now. The cough medicine I got last week hasn’t helped.”

I opened his chart in the computer. He had been in six days earlier. A colleague had noted that his lungs were clear and diagnosed him with a viral illness.

“Let me listen to you”, I said.

He had scattered rhonchi and a few wheezes, and at the bottom of his right lung I heard faint crackles.

“You need an antibiotic”, I said, and made sure he didn’t have a fever and that he wasn’t too short of breath.

I created a “new telephone encounter”, documented my findings and e-prescribed an antibiotic for him.

“Be sure to come back if things don’t turn around quickly”, I said.

There’s no way I could charge him for a brief visit. And that’s got nothing to do with whether I wanted to increase my productivity numbers or our clinic revenue.

In this day and age, there is no such thing as a quick visit to make sure someone is okay or to avert clinical deterioration or disaster.

In order to meet all our quality requirements for being a patient centered medical home and all the other ways we are judged and measured, a visit note has to include, even if the patient was seen just one single day before, a complete medication reconciliation, updated past medical and surgical history, social history and specific questions about any other care the patient has received since last seen. In our EMR it would be impossible to get around all these clicks by building a note template that says nothing has changed since last time; the computer tracks the actual clicks we make in the EMR.

So in cases like Harry Brown’s, I have these choices: Treat him for free right then and there, make him come back some other time when we have time for all the extras, or send him to walk-in care in the big city.

My choice is clear, but I can’t help wondering if the people who created the requirements for overambitious repetitive inquiries into the past history of people we already know quite well really understood that instead of becoming more patient centered, we would start giving free care or turn away patients and thereby fragmenting their care.

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