Cooperating for better care.

Fred N. Pelzman

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Time pressure on physicians makes teamwork more important

Fred  N. Pelzman, M.D., writes in his Med Page Today column that physicians’ short time with physicians means teamwork is essential.

Among his suggestions:

  • “Consider scheduling an appointment with PCP for medication review.
  • “Consider scheduling an appointment with PCP for pain assessment in older adults.
  • “Consider scheduling an appointment with PCP for functional status assessment.
  • “Consider scheduling an appointment with PCP for advance care planning.
  • “Consider scheduling an appointment with PCP for use of high-risk medication.
  • “Consider educating member/caregiver regarding cardiovascular and respiratory symptoms.”



‘Our patients are not PowerPoint slides’


Structure of a EHR system.

“Why, in such a complex environment, have we allowed ourselves to become subject to an electronic health record that is not anywhere near as responsive as we would like, when it comes to making things better for patients and providers and the rest of the team taking care of all of these patients?”

“It seems strange that since healthcare providers across this country are paying thousands, tens of thousands, hundreds of thousands, and even millions of dollars to the EHR vendors, and since getting this right is so critical to being able to adequately care for patients in the challenging healthcare environment we are all practicing in, you’d think that the companies that make these things would be getting the message that what we have is just not enough.”

“As much as we’ve complained about these things through the years, it feels like we’ve been unable to move the needle away from the creators of the program controlling the content, how it looks, what we have to do to click the buttons to get through our day, rather than us, those of us who take care of the patients, who, believe it or not, probably know best what an EHR really should look like.”

“Our patients are not PowerPoint slides, and we are not presenters standing up in front of an audience where it’s okay if the slides don’t look exactly like you wish they looked.”

To read his whole essay, please hit this link.

How to get a perfect chart out of a medical appointment

Fred N. Pelzman, M.D., a New York primary-care physician, writes (amusingly) in Med Page Today about how “I made patient’s chart perfect.”

Among his remarks:

“Despite doing nothing, we were as updated as he was going to get.”

“Now, none of {the patient’s} refusals {to address various medical issues/opportunities} are permanent; the next time he comes in the EHR likely will flag me again, highlighting things I need to ask him. If I want, I can make them permanently silent, but I always think it is worth leaving them as fluid, so that I can try once again the next time he comes in.”

“None of this documentation and charting made my medical record for him a better true record of the care I provided that day. While, in fact, in the assessment and plan I describe how I tried to encourage him and explain to him why many of these items were probably good for him in his terms of his long-term health, the clicked boxes that gave me a clean healthcare maintenance field in the electronic health record really didn’t leave much of a trail for another provider to follow.”

He concludes:

“If we work towards a better more interactive more cooperative electronic health record, utilizing the entire team, and our patients as well, then maybe all our charts will end up being nicely tucked away, everything clean and clicked and ready to rock our patients to better health.”

To read Dr. Pelzman’s piece, please hit this link.

Refining the handoff


Fred N. Pelzman, M.D.,  in a piece headlined “Refining the handoff,”  in MedPage Today, discusses the tricky art of deciding how to discharge patients from the ER.

Among his remarks:

“We put massive resources in place to try and improve the continuity of our patients with their primary-care providers, which has always been fractured as the residents rotate away and spend less and less time in our practice. Therefore, appointment priority is given to the primary-care physician, and someone needs to clearly state why an exception to this rule is being made.”
And “{o}ne of the problems has been that, for a great majority of these appointments, .. protected emergency room follow-up rapid discharge appointments end up not being really useful, not really helping the patient, and often not being necessary at all.”

”Now to be honest, a lot of this may be unfair. It reminds me of the game of Post Office, where a message gets passed along and the substance of the message changes as it goes from mouth to mouth.”

”{W}e need to streamline and improve communications, we need to make sure that the right patient gets the right appointment with the right provider at the right time.”
“{One physician} told me about an idea he has been toying with, trying to involve the primary-care doctors themselves in a discussion with the emergency room provider, so that they can all agree on the goals of these rapid discharge appointments.
“It is essentially a primary-care consult, with the goal of deciding what type of access, with what sort of acuity, and with clear questions asked to be answered.”

“In hashing this out, we came up with the idea of the emergency room doctor who is preparing to send a patient home speaking on the phone with one of our primary-care physicians, and having an actual conversation, a warm handoff, answering a preset group of questions to help make sure these patients get the care they need.
Does each patient have a primary-care doctor? Does the emergency room provider think the patient needs to be seen within X number of days? Why? What is it that you want us, as the outpatient primary-care provider, to assess, to follow-up on, to rethink?”

To read all of Dr. Pelzman’s piece, please hit this link.

A practice’s ‘bump list’ approach to patients


Fred N. Pelzman, M.D., writes of his practice’s “bump list” approach:
“Patients are advised that they should arrive in the practice at the beginning of either an afternoon or morning session, and expect to wait, and expect to have a provider take care of this single-focused issue.
“Explicit instructions are given: these are not routine care visits, management of their multiple medical problems, or a laundry list of complaints, essentially nothing but what they are put down by the triage team as needing to be seen for.
“And one of the stipulations is that at the end of each one of these bump list visits, each patient will leave the practice with a follow-up appointment scheduled with their primary care provider — no exceptions.

“Our hope is that patients will leave the practice satisfied, and with a plan for follow-up, and that the providers will get a little bit of a flavor of what has traditionally been going to urgent care or the emergency room, but is probably more appropriately handled in the outpatient setting.”

Too many moving parts


“Our time is short, and we are bombarded with prior authorizations, faxes, in-basket messages, emails, e-prescribing requests, transportation forms, home care forms, more things to sign, click, approve, renew, redo….”

“Clearly we need to reinvent some of these systems, to simplify and streamline things, to help providers practice up to their license, before the joy of practicing medicine is completely lost.”

“This morning, one of my interns came to me crushed and understandably flustered by the deluge of messages, faxes, forms, urgent requests for pain medicines, and assistance from other providers in the practice, that he been buried under for the past few days. He felt that while he was seeing patients he was stressed and overwhelmed, trying to figure out which of their complaints were critically important, potentially life-threatening, or could be delayed to another day.”


Healthcare quality is more than audit results

Fred N. Pelzman, M.D., the New York writer and internist, writes in MedPage Today:

“The Institute of Medicine’s report ‘Vital Signs: Core Metrics for Health and Healthcare Progress’ from the Committee on Core Metrics for Better Health at Lower Cost, attempts to define such a set of metrics we need to measure to ensure that we are taking the best care of each individual patient, each group of patients, and each population that we are providing care for.”


But, he warns, “All of these checkboxes, audits, database reviews, lead, in more cases than not, to us paying lip service, checking a box, testifying that we have reconciled meds or counseled a patient on healthy lifestyles, come up with a plan for weight loss, ensured that they will definitely take their medicines. Quality is more than audit results and patient satisfaction scores.

“We risk catering our care to the measured outcome, rather than to true quality and what is best for patients….

“As we build up patient-centered medical homes, Accountable Care Organizations, and other models of care, we need to continuously ensure that we are not being overwhelmed with mindless tasks that add no benefit to our patients, that by default cause us to click a box to get through our day’s work….”



A farewell visit in the outpatient world


Fred N. Pelzman, M.D., tells of a resident growing teary-eyed over a long-time patient farewell visit.

“Out here in the outpatient world — in the ‘real world’ as we like to call it — the relationships may start out smaller {than in a hospital}, but they have great potential to grow. We may be fine-tuning or wholesale changing medicines, learning about barriers to medical literacy, overcoming patients’ fears of undergoing certain tests or procedures, or adapting our preset notions of what is right and best for our patients to a patient’s own set of personal and cultural beliefs. This builds connections, and it only matures with time.”

‘There’s gotta be an app’ to reduce patient chaos

Fred N. Pelzman, M.D., laments the number of patients who show up unannounced and those who constantly forget their appointments,   even as providers are told to provide ever more “access”.

He suggests:

”The insurance industry should be able to develop a more modern system of monitoring the use of resources by their patients, … maybe by monitoring these things electronically through claims data, actively informing patients each time they use up one of the benefits they have remaining.

”There’s gotta be an app for that …

”Taking the doctors out of this process could improve our quality of life and the satisfaction of our patients. And no doubt the system’s efficiency will also dramatically improve, and savings will undoubtedly follow.”


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