Baby Goes Grocery Shopping (Cute Video). You Might Be Surprised At His Favorite Food!

Little ten week old baby Zachary went grocery shopping with us today.  Up and down the isles we went.  We asked him what he wanted for dinner.  You might be surprised at what he picked for his favorite food.  

For more Zachary, you can visit all his blog posts and videos as well.

ARDS with Pneumothorax (CXR Image). All ICU Patients Should Have The Benefit of a Palliative Care Consult, By Default.

Acute respiratory distress syndrome is not a good thing to have. However, also getting a pneumothorax along with your ARDS takes you from very bad to very worse. A reader shared with me these striking images.  The young and healthy human body is an amazing regenerating machine capable of incredible recovery from incredible illness.

The abused life of the chronically debilitated elderly is not.  Chronically debilitated elderly folks do not recover from ARDS with pneumothorax. Young people might.  For the debilitated elderly, this is a perfect chance for an  ICU palliative care consult for no other reason than compassion and the alleviation of pain and suffering.

The question is, do you start the process at the end of their dying process or at the beginning.  My experience, as a hospitalist, is that we commonly start the process at the end.  We need to change that.   Unfortunately, none of us have been trained to define the appropriate palliative care population.  It really is a gut fealing consult.    Which is why, I believe, all ICU patients should have a palliative care consult, by default, on admission.

Just like all of my patients with alcohol abuse get an intervention evaluation on my service, the same should apply to all ICU admissions.  That way, the dying process is applied equally to all patients  and physician consultants who don't understand what palliative care is don't feel like we, as hospitalists, are giving up on their patients as well  by picking and choosing patients we think aren't going to make it.  Right now, all I have is a gut feeling and a decade of experience.  Palliative care offers me evidence, one way or another.

My hope, eventually, is that we have a national standard for system wide screening  for palliative care evaluation  on admission.  That way, limited resources are focused on patients that would benefit the most from having these important talks.  And I can assure you, from a bean counting stand point, the return on investment would be more than palatable.  It would be delicious.

Photo Letter Collage with Smiley Zach (Cool Picture)

I caught all these pictures in a five minute random, spontaneous photo shoot today with little baby Zach.  I  placed the pictures into a photo letter collage maker.  As you can see, he's a man of many cute faces.

Click image for full size version.

Young Buck Onesie: Too Cute Not to Puke (Picture of the Day).

Young buck onesie wins today's award for too cute not to puke.  Here's Zachary snuggling with Marty and Cooper.  See more of Zachary and Marty/Cooper at all their blog posts.  

For other great onesies, visit

• Funny Halloween onesie:  I want my MUMMY!
• Camouflage onesie
• Future Potbelly! onesie
• Funny still living at home onesie
• Tax deduction onesie
• Onesie tie business attire
• Custom made onesie
• Handsome like daddy onesie
• Laughing my diaper off (LMDO) onesie
• Moose onesie with a hoodie

Checklist Prompting Study Reduces Mortality By 50% in the ICU. Nurses Need To Take Charge of the Process.

Over the last few years, you may have heard a lot about the value of checklists in ICU medicine and their ability to reduce mortality, reduce cost and reduce length of stay.   But a recent study took the concept one step further and suggested that checklists by themselves may not be  effective unless physicians are prompted to act on the checklist.

As reported in the American Journal of Respiratory and Critical Care Journal, a single site cohort study performed at Northwestern University Feinberg School of Medicine's medical intensive care unit compared two rounding groups of physicians.  One group was prompted to use the checklist.  The other group of physicians had access to the checklist but were not prompted to use it.

EMR Comparison

Successful software implementation starts with choosing the right system. This  checklist contains over 50 of the most important features to look for when evaluating:

• electronic medical records
• medical billing software 
• scheduling software
• technology, security and certifications

Download now and get started today Other useful information is available at my EHR Resource Center.

LINK TO E/M POCKET REFERENCE CARD POST EM Pocket Reference Cards Using Marshfield Clinic Point Audit One Hospital: (Admit/Consult) One Side, Follow-Up On Other Side $10.00 One Clinic: (New/Consult) One Side, Established On Other Side $10.00 Two Hospital Cards $16.00 Two Clinic Cards $16.00 One Hospital Card + One Clinic Card $16.00 Two Hospital Cards + Two Clinic Cards $29.00 Click image for high definition view

What they found was shocking.  Both groups had access to the checklist.  However, patients followed by physicians who were prompted to use the checklist had

• Increased ventilator free duration
• Decreased empirical antibiotic use
• Decreased central venous catheter duration
• Increased rates of DVT prophylaxis
• Increased rates of stress ulcer prophylaxis 
• Lower risk adjusted ICU mortality
• Lower risk adjusted hospital mortality
• Lower observed-to-predicted ICU length of stay

 Interesting indeed.  What they found was that using the checklist without prompting did not reduce mortality or length of stay.  It's not the checklist that's important.  It's addressing the checklist that matters.

This makes sense, completely.  In fact, here's what happens in a patient's chart when standard orders are placed and meant to be reviewed and addressed by the physicians.  Nobody pays attention.  Nobody claims ownership of the process.  Everyone assumes someone else is going to address it or they simply aren't paying attention.  Or even more likely, additional orders get written and placed in front of the checklists and  these blank checklist order sheets work their way farther and farther into no man's land in the chart.  I see it every day.

One of my goals as a hospitalist at my institution is to eventually  get a system wide checklist order set  implemented for all patients in the hospital.  There are many things I know, intuitively, that we do to patients every day that increase cost and length of stay and probably increase mortality as well but nobody has defined a process to make addressing them a daily priority.  Things like

• Daily assessment of telemetry need
• Foley catheter removal criteria
• Central line removal
• Easily accessible start time for antibiotics with defined stop dates
• Daily weights
• Changing IV to po medications 
• VTE prophylaxis reminders

This study is important.  What it tells me is that having a checklist available is not enough.   It needs to have daily reminders and communication between the physician and the RN.  

This is further vindication for physician-RN rounds to occur every day. I ask to speak to the patient's nurse on every patient, every day, because I know that they know stuff that isn't written anywhere and is not easily available anywhere.  I don't read nursing documentation prose because I talk to the nurse.  

Perhaps, someday, every day, patient's on all floors will have daily reminders addressed in one easy to access centralized process that nurses, respiratory therapists, pharmacists and all other hospital team members can communicate their recommendations at the bedside and physicians are prompted to act.

Now, if I can just get the  hospital decision makers to stop viewing this as another in a long series of worthless, time consuming required nursing duties and get them to understand they need to own the process in the interest of patient safety.    Nurses are the patient's greatest asset and this process could help their patients shine in their recovery.  What they forget, and I know this to be true, is that if we can communicate daily, face-to-face, between physician and RN, then that is time well spent reducing all the other complications and time wasting activity that eventually creates chaos in the hospital when complications ensue.  It's like the 5Ps of hourly rounding by nurses.   We need to add a sixth P:  Prompt the physician.

I think every hospital in this country should strive to have a daily checklist on medical rounds and every patient should have the right to have physician-nurse reminder prompting as a matter of patient safety.  Now that's a concept worth fighting for.  And I wonder where the Joint Commission is.  Oh yeah, their busy shutting down hospitals because a physician didn't sign off a verbal order that was carried out 23 hours and 59 minutes after the fact.

Baby Infant Color Splash Picture Slide Show Presented In High Definition By Zachary.

I've taken over a thousand pictures of Zachary in the last 2 months.  Here are some of my favorite  pictures in a color splash slide show.  I took many of them with my new Canon EOS Rebel T2i 18MP Digital SLR. Enjoy the love.

For more Zachary, you can visit all his blog posts and videos as well.

Presidential Autopen OK To Spend Trillions; Doctor's Stamp Not OK to Collect $50

In what has to be one of the biggest hypocrisies ever for big government, we learn that Obama and Co. have their very own presidential autopen that was recently used to sign a bill into law, specifically extensions of certain provisions of the Patriot Act.  That's right folks.  Obama's presidental autopen is now the most expensive weapon on the face of this earth.

How hypocritical.  Doctors are banned from using their own doctor signature auto stamp to bill Medicare for services provided, yet Obama and Co are now employing their very own presidential autopen, without even his presence, to sign bills into law.

Perhaps he has set a new legal standard for doctors every to challenge in court.  If the presidential autopen is a viable standard for matters of Federal importance, then a doctor's stamp should be good enough for The Medicare National Bank.  Any lawyers wish to take up the cause?

Baby In a Frog Outfit: Gut Wrenching Dose Of Cute

I don't care who you are or where you come from, a baby in a frog outfit is just darn cute.  Here's Zachary showing us the frog eye look in his very own frog outfit.  He's just over two months old here and pushing eleven pounds of joy.  Although, by the look of things, I'd say he's just about ready to kick someone's butt.

 For more Zachary, you can visit all his blog posts and videos as well.

Hospital Food Trays Dangerous and I have Picture Proof!

The hospital is a dangerous place.  Morbidity and mortality can come out of anywhere, including from hospital food trays.   A while back a hospital patient was critically injured when their wall mounted IV pole came crashing down on their head, resulting in a skull fracture. 

Well, I've discovered a new danger for patients that I think requires immediate action by the Joint Commission.  We all know that, due to OSHA regulations, hospital employees are prohibited from having food and drink at the nurses station.

It's time, now, as a matter of patient safety, to prohibit food and drink in patients' rooms as well.  Here's what happens when a patient's hospital food tray is filled with their breakfast and I go to move the table out of the way and the tray goes flying off into the patient's lap.

Unforeseen dangers of Hospital Food Trays.

I have reported myself to the Joint Commission for this shocking danger to patient safety.  I have asked that they personally add hospital food trays to their ever growing list of things to ban in the hospital because they can.  In today's safety environment, there is simply no excuse for any patient to ever be harmed again with hospital food trays.

As a physician wishing to do no harm, I am requesting one of two things.  Either patients not be allowed to ever eat food again in their room or physicians be required to undergo a rigorous hospital food tray safety training program with yearly continuing education requirements to prove their proficiency in hospital safety standards at the bedside.   

I'm just glad the patient wasn't gravely injured and this mess didn't  scare the cleaning lady too much.

Betta Fish Pet Stories? Please Lord, Don't Let Us Kill The Neighbor's Betta Fish

It turns out we are the proud new parents of one 11 year old neighbor's betta fish for the next ten days.  In addition to our angels Zachary, Marty and Cooper, we now have a little betta fish pet to take care of.  Mrs Happy is quite nervous.  She's had a few fishies die in her lifetime.  She knows how delicate they can be.

The kid isn't worried though.  He says just feed the fish two to three pellets of food every day and the little fella will be fine. Feed him anymore and he'll have poop floating all over the place. I'm sure cleaning the fishbowl isn't like picking up dog poop.

We don't need to wake up one morning to find a dead betta fish floating in the water.  I think that would crush the spirit out of that little boy.  And Mrs Happy might get a bit teary eyed too.  So swim little betta fish.  Be happy.  And whatever you do, don't die on us.

If you'd like to say a prayer on behalf of our pet fish parenting abilities, please do so now at your convenience.  Thank you.

Night Shift Survival Food for Hospitalists

It's nice to know where to go and who to call during a busy hospitalist night shift if the doctors' lounge food has been picked clean to the bone and all that is left are two day old dry roast beef sandwiches and some crystallized cups of ice cream.  

Here's a little midnight survival food I found waiting for me in the ER as I packaged up hospital admission after admission during the wee hours of the morning.   By the time I was done clearing the  ER board, I felt like I was at the Texas Roadhouse peanut restaurant.  It's a good thing I have teeth.  You don't need teeth to eat meat, but you do need teeth to eat hospital night shift  survival peanuts.  I learned that from the 'Things Homeless People Can Teach You' file.

Hospitalist Night Shift Survival Food:  PEANUTS!

Do note however, that peanuts are not considered a snowstorm survival food in Atlanta.

EMR Comparison

Successful software implementation starts with choosing the right system. This  checklist contains over 50 of the most important features to look for when evaluating:

• electronic medical records
• medical billing software 
• scheduling software
• technology, security and certifications

Download now and get started today Other useful information is available at my EHR Resource Center.

LINK TO E/M POCKET REFERENCE CARD POST EM Pocket Reference Cards Using Marshfield Clinic Point Audit One Hospital: (Admit/Consult) One Side, Follow-Up On Other Side $10.00 One Clinic: (New/Consult) One Side, Established On Other Side $10.00 Two Hospital Cards $16.00 Two Clinic Cards $16.00 One Hospital Card + One Clinic Card $16.00 Two Hospital Cards + Two Clinic Cards $29.00 Click image for high definition view

What's the Best Way To Get a Doctor To See Me If I Don't Have Any Money? Rob a Bank Like James Richard Verone.

Ever wonder how is the best way to see a doctor if you don't have any money?  Well, you can go to the emergency room.  There will always be a nice pleasant cheerful ED doctor waiting to meet your every need with a smile and you'll never have to pay a dime.

Or, if you're more into making an actual appointment with a physician, just rob a bank for one dollar, like broke convenience clerk James Richard Verone did on June 9th, 2011 in Gastonia, North Carolina.   That way, you'll get all the free doctor's visits, surgeries and hospital admissions our taxes can buy as city, state and federal governments are required to pay for the hospital bills of jailed patients admitted during incarceration.

This guy's looking for surgery and then retirement on a beach with his social security.  He'd better hurry.  America is going bankrupt faster than an ER doctor can say GOMER.

Image: Gaston County Jail

Hot Summer Nights Are Here

Go celebrate the first summer Grand Rounds of the season with some hot Internet finds.

What Doctors Really Think But Are Afraid To Say Out Loud

You ever wonder what doctors really think but are afraid to say out loud?  Here's one example I heard:  

"I wish all my patients were on a ventilator"  

There's a reason vented and sedated patients are considered desirable.  In addition to the obvious economic benefits of

• ROS unobtainable
• Billing critical care CPT 99291, 99292

There are the less talked about, but equally pleasant side effects most hospitalists, ER doctors, cardiologists, gastroenterologists, pulmonologists,  surgeons, infectious disease doctors, endocrinologists, psychiatrists, rheumatologists, dermatologists, nurses, respiratory therapists and physical therapists wouldn't admit, but would agree, without hesitation.  As a general rule:

•  Patients on ventilators are just faster, easier and more pleasant to take care of. 

That makes sense.  A sleeping patient is an easier patient.  It's true whether you're a doctor or a nurse.  Don't hate me.  I'm just the messenger of truth.

Cigarette Box Graphic Ad Warnings (View All Pictures and Images) New From FDA and Coming September 2012

The FDA has announced the first change to cigarette warnings on cigarette boxes in 25 years.  Starting in September 2012, a series of graphic pictures and images will be displayed on all cigarette boxes in the United States, as an additional reminder to help get smokers to quit smoking for good.

As per the FDA website:

Placement of New Warnings on Cigarette Packages and Advertisements

Starting in September 2012, the new cigarette health warnings will appear

• on the top 50 percent of both the front and rear panels of each cigarette package.
• in the upper portion of each cigarette advertisement, occupying at least 20 percent of the area of the advertisement.

Here's one example of the new graphic cigarette box images to appear in the near future

FDA copyright statement:  Unless otherwise noted, the contents of the FDA Web site (www.fda.gov)--both text and graphics--are not copyrighted. They are in the public domain and may be republished, reprinted and otherwise used freely by anyone without the need to obtain permission from FDA. Credit to the U.S. Food and Drug Administration as the source is appreciated but not required. 

If you want to view all the new warnings, the FDA has  all examples of all nine new cigarette box graphic warning ads.  They even come in Spanish.

Here's what the convenience store counter will look like in just over a year. (cool interactive photo)

For additional smoking resources, visit:

• Quite smoking for good (or you'll get cross eyed)
• Quit smoking right now (the most rapid nicotine detox program ever)
• CPT 99406 and 99407 (How to bill for smoking cessation consults)
• Smoking vaccine?  Really?
• Hospital smoking bans.  Common sense people.
• Hairdresser smoking?  What should I do?
• New York's public smoking ban in outdoors.  Three cheers!
• Free Chantix?  I wouldn't touch the stuff anymore.
• My smoking lecture.
• Tobacco farming insight.  Shocking?  Or not.
• How many people die every year from smoking?  Too many.
• Smoking with oxygen is not safe except under only one circumstance.
• Chain smoking 2 year old.  How sad.
• Chantix lawsuits here we come.
• Average cost of a pack of cigarettes.  Nice.
• Smokers linked to lower IQ. 
• Four pack per day smoker.
• Ever heard for fourth hand smoke?
• Smoking causes pet cancer.  Shame on you.

Hospitalist vs ICU End of Life Palliative Care Consult Xtranormal Medical Video Presentation

Here's the latest in my Xtranormal medical videos.  This one is Hospitalist vs ICU End of Life Palliative Care Consult.  A peek behind the curtains of ICU care, Xtranormal hyperbole style.

Find other hilarious Xtranormal Medical Videos.  Some are Happy originals.  Some aren't.  I think they're all funny.

The Greatest Father's Day Gift Ever (Picture and Video)

Here is a video of the greatest Father's Day gift ever.  A family of love.  Who needs anything else?  Here's seven week old Zachary being cute as cute can be.  And call me crazy, but I swear he says "I love you" at the 33-35 second mark.   How do I know if my child is going to be smart?   That's how.

Zachary, Marty and Cooper 

My First Father's Day Card Loot

Marty and Cooper disagree with this last picture as I've been their father for almost eight years.  Don't worry you guys.  We know how important you are, even if no one else sends us cards to celebrate your love. 

For more Marty and Cooper action, you can read all their blog posts, catch them at their YouTube channel  or watch their two beautiful slide show presentations, the full color slide show and the all black and white slide show, both available for viewing in my side bar as well.

For more Zachary, you can visit all his blog posts and videos as well.  

Strangest 911 Call Ever? How 'Bout Because Your Newspaper Wasn't Delivered!

I've seen some pretty strange 911 calls through the years.  There's the Andy Dick 911 call.  You think that's strange?  How about that mother who called 911 because her son wouldn't stop playing video games.    911 isn't only being used by strange Americans.  It's being used to reduce family practice expenses as well.  And the hospital implemented patient initiated rapid response is like a 911 system in and of itself.

Indiscriminate use of 911 communications is becoming so rampant that some cities are actually charging for 911. I don't blame them one bit.  There are people in this world who call 911 for some of the strangest, dumbest and most ridiculous reasons ever.  Like these people who called 911 because nobody delivered their newspaper that morning.

If I was that 911 operator, I would have told them to go to their nearest ER.  

The Business of Grand Rounds

Go check out this week's Grand Rounds for the Internets best offering of medical stuff.

Baby Learns Disco Dancing Moves (Video), With a Little Help From Daddy.

Ok, I know learning any new trade takes time and baby steps.  But I'm confident little baby Zachary will eventually have all the fine disco moves down with a little help from daddy. It's not exactly baby yoga with Elana Fokina.  And it's not  exactly the dancing baby, Beyonce style, but it's a start.   And everyone has to start some where.

Someday Zachary, you're going to be a disco dancing star.  I just know it.  For more Zachary, you can visit all his blog posts and videos as well

99253: How To Bill CPT® 99253 Hospital Consult Free E&M Coding Clinic

If you've found this post, you're looking for information on how to bill CPT® 99253, the inpatient hospital consult E&M code.  And I'm going to give you a free coding clinic on how to do just that.  I am a hospitalist who has been in private practice for almost a decade.  I have spent hundreds of hours studying the ins and outs of evaluation and management coding. Just remember one thing, Medicare no longer recognizes any of the inpatient consultation codes.  You are instead directed to use the initial hospital encounter codes 99221-99223 for any Medicare beneficiary.   Some insurance still pay for consult codes and that's what you're here to learn about.

If you haven't seen my other medical billing and coding lectures, you're missing out on the opportunity to submit the correct CPT® code every time and accurately get paid for the work you are providing your patients.   You're also missing out on tens of thousands of dollars of revenue that could be yours simply by understanding how E&M works. 

When you get a chance, make sure you check out my other free lectures on the inpatient hospital follow up CPT® codes 99231, 99232 and 99233.  You'll also find information on my Initial hospital admission codes 99221, 99222 and 99223 which, as you'll find out require the exact same documentation as the observation codes 99218, 99219 and 99220 respectively.  Interestingly enough, these codes also require the same documentation as admit discharge same day codes 99234, 99235 and 99236, respectively.  

Now it's time to learn about how to bill CPT® 99253, the mid level hospital consult code.  There are five hospital consult codes 99251, 99252, 99253, 99254 and 99255.  I have never billed a 99252 or 99251.  Hospitalized patients will meet the criteria for a 99253 or higher almost 100% of the time, if you know what you need to document.

As usual, read the following:

I am not a licensed  coding compliance officer. I am a hospitalist physician with years of experience studying this stuff.  Read at your own risk.  My interpretations here are based on my review of the 1995 and 1997 guidelines and the CMS E/M guide along with the Marshfield Clinic point system for medical decision making.

The Marshfield Clinic point system  is voluntary for Medicare carriers but has become the standard in most parts of the country.  However, you should check with your own  Medicare carrier in your state to verify whether or not they use a different standard than that for which I have presented here on my free educational discussion.

Some carriers in some states utilize the  Trailblazer EM tool.   There are a few key differences with Trailblazer vs Marshfield in how Medicare carriers are to interpret evaluation and management documentation.  Here is a summary of those key differences.  Here is  the actual link to the Trailblazer E/M Audit reference pdf.  If your carrier uses Trailblazer, this discussion may help you, but these additional resources should be reviewed as well for clarity.

How does the AMA define a CPT® 99253?

Inpatient consultation for a new or established patient, which requires these 3 key components:  A detailed history; A detailed examination; and Medical decision making that is of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 55 minutes at the bedside and on the patient's hospital floor or unit.

I have now developed a card (seen below) that I carry around with me  at all times to help me understand all the rules of  CPT® medical coding for this 99253 hospital consult.

The following is the exact bare minimum you must do in order to qualify for a hospital consult  CPT® code 99253.  These rules are very similar to the low level hospital admission codes 99221, 99218 and 99234, but there are some subtle differences,  unlike the hospital consult codes 99254 and 99255, which require the exact same E&M criteria as their respective admit/initial hospital visit codes..   So here it is.  The 99253.  You need history, physical AND decision making to qualify in their respective levels, unlike hospital follow up visits that need just 2 out of 3 areas.  Remember, for consults, you need 3 out of 3:

History (You need all three of these components)

1. 4 elements of the HPI (character, onset, location, duration, associated signs etc.  OR the status of 3 chronic medical conditions.  AND
2. 2 review of systems.  AND
3. 1 area from Past Medical, Medications, Allergies, Family, Social history

AND

Exam

1. Extended exam of the affected body area and other symptomatic or related organ systems OR 6 areas (2 bullets each)  OR 2+ areas (12 bullets total).  Documenting three vitals is considered a bullet

AND

Decision Making

• Diagnosis: 2 points
• Data: 2 points
• Risk: Low

For the Decision making component, remember, you need the highest two out of three from diagnosis, data and risk.  

So here is a clinical example of a mid level  hospital consult CPT® 99253:

Reason for Consult:  Red leg:

HPI: 28 yo Male with 3 day history left calf pain.  6/10, dull, constant.  Associated edema, erythema.

PMH: Smoker

Exam: 120/80  85  102.7 temp, well appearing

heart:  RRR without murmur, good femoral pulses

lungs:  clear to auscultation, normal effort

abdomen:  soft, no palpable liver

Skin:  erythema lines marked and noted, induration present

Musculoskeletal:  normal ROM knee, no clubbing, cyanosis

ROS:  No CP or SOB. Cardiac and pulmonary systems reviews negative.

Plan

 Reviewed case details and antibiotic choice with the ED physician.  Plan IV antibiotics.

That's all you need folks.  A very straight forward mid level CPT® 99253 hospital consult. Several things to note.  On history and physical examination,  you can write "normal"  and it constitutes a full exam of that body area.  You cannot write "abnormal"   

 As any great hospitalist knows, what CPT® code you bill is entirely dependent on how you document, not how much you document. In this case, you can fully document a CPT® 99253 with out writing a novel.  It's not how much you write, it's what you write that matters. 

LINK TO E/M POCKET REFERENCE CARD POST EM Pocket Reference Cards Using Marshfield Clinic Point Audit One Hospital: (Admit/Consult) One Side, Follow-Up On Other Side $10.00 One Clinic: (New/Consult) One Side, Established On Other Side $10.00 Two Hospital Cards $16.00 Two Clinic Cards $16.00 One Hospital Card + One Clinic Card $16.00 Two Hospital Cards + Two Clinic Cards $29.00 Click image for high def view

EMR Comparison

Successful software implementation starts with choosing the right system. This  checklist contains over 50 of the most important features to look for when evaluating:

• electronic medical records
• medical billing software 
• scheduling software
• technology, security and certifications

Download now and get started today Other useful information is available at my EHR Resource Center.

Death of America (Video): 3 Part Act Through The Eyes of a Squirrel

Happy's sister-in-law took this raw footage of a squirrel. This video I made sums up the current state of Medicare and Social Security in less than two minutes.    It's titled Death of America:  3 Part Act Through The Eyes of a Squirrel.  America's Entitlement Mentality in a Nutshell.

It's a black squirrel.  Don't read anything else into it.

Sleep Deprivation With A New Baby (Pictures of Sleep vs No Sleep)

Here's a couple pictures showing sleep vs sleep deprivation with our new baby.  For more Zachary you can visit all his blog posts and videos.

Sleep Deprivation

Sleep

Tummy Time Exercises With Italian Greyhounds (Picture and Video Fun)

Our little Zachary is growing up so quickly.  Where did those last seven weeks go?   Here he is in this video strengthening his neck muscles  with his tummy time exercises.  Marty, our almost eight year old Italian greyhound decided to get in on the action.  It's really cute, especially if you're a dog or Italian greyhound fan.  Enjoy the love.

For more Marty and Cooper action, you can read all their blog posts, catch them at their YouTube channel  or watch their two beautiful slide show presentations, the full color slide show and the all black and white slide show, both available for viewing in my side bar as well.

For more Zachary, you can visit all his blog posts and videos as well.  

Text Out Rounds App: The Newest Check Out Process For Hospitalists!

Check out is that process where physicians taking pages and calls for their partners discuss relevant patient information before signing out for the day.  Multiple checkouts are one aspect often cited as a deficiency of shift model hospitalist programs.  Well, I'm here to say that the  check out process is here to stay.  Just about every doctor of every speciality checks out patient responsibility to a partner, frequently on a daily basis.

However, as a hospitalist, I'm leading the charge to make hospitalist efficiency and nursing efficiency a part of our daily existence.  It settles the  HIPAA and texting concerns.  It's also about being efficient.  With that said, I'm here to introduce to the world a revolution in check out rounds.  It's called the Text Out Rounds App.  It's not your average everyday checkout.  It's quick and to the point.  It's a super secret project created by myself with the help of a major software company to provide an App where physicians could text each other quickly and easily without including any patient specific details that would not comply with HIPAA.  In other words, the Text Out Rounds App is the most efficient HIPAA compliant checkout process available to date, as long as you don't text patient identifying details.

For $59 and change, you can download the app.  Then go to your routine smart phone contact list, find your physician partner contact in your phone and use your normal texting platform to text them your Text Out Rounds.  It's perfect.  This Text Out Rounds App is going to change the way we do business.  The future is here.  And soon, you'll be able to purchase my pocked sized quick reference coding card as a bundle with my Text Out Rounds App.    

Remember, keep it brief.  The on call doctors just don't care about all the specifics.     Text Out Rounds, here we come.  To kick things off, here's an example of my highly anticipated Text Out Rounds App coming soon that I used today to send my partner everything she needs when she picks up my service tomorrow. 

TEXT:  I left you seven patients. They all have borderline personality and none of them speak English.  Happy.

Any questions?

Go here for more humor about texting in the hospital.

DO NOT KNOCK Funny Door Sign and Slogan (Picture)

I found this sign on the door into the radiologist's reading room.   I've never seen a do not knock sign before.  I don't care who you are.  That there is some funny door sign humor.

For other funny signs, visit

• Funny homeless signs
• Funny church signs and slogans
• Drunks in the area street sign
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Posterior Labral Tear: My Shoulder Pain's Cost of Travel Through MRI, Rehab, Orthopaedics and Intra-Articular Injection

Well, it's been awhile but my shoulder is now pain free.  And it turned out to be a posterior labral tear.  I wrote months ago about my electrical stimulation shoulder physical therapy.  I self referred myself to get PT on my persistent shoulder pain.  I made it to eight therapy sessions and had a significant improvement in my range of motion, but not the pain component.   I was only a no show for one appointment as I got my dates and times mixed up.  These visits  consisted mostly of  a resistance training  component and an E-stim component.  On two occasions they performed ultrasound with topical steroid therapy on my persistently painful right shoulder.

Then came baby Zachary.  With his birth and delivery, we met  our $3,500 total out of pocket HSA  plan deductible for the year.  So I figured, what the heck.  With a zero copay for all medically necessary services for the rest of 2011, why not get an MRI of my shoulder to see if more clarity of my shoulder's pathology could be defined.   Unlike physical therapy service, Happy's Blue Cross Blue Shield insurance requires preauthorization  for my MRI.   So I caught one of the orthopaedic surgeons in the hall and he had his office call me directly to fill out the paperwork.  It was much easier than the pain patch Lidoderm preauthorization madness I went through for Medicare Part D.

Within minutes I had my MRI scheduled at Happy's hospital for the next morning.  Here  is a picture of me strapped into Happy's Hospital Seimens 3T-MRI for my MRI EXT JNT UPP W/O CONT/RT (MRI extremity joint upper without contrast routine) to get an image of my right shoulder. I must say, the MRI tech was perfect in their implementation of the  Studer Group AIDET method of customer service.  Great job! I'm, certain Happy's hospital will pay you oodles of  extra cash that will start rolling in once Medicare starts paying for health care based on patient satisfaction surveys in just a few short years to come.

I figured I'd follow my own HSA tips and get my MRI this year while my deductible was met.  Free MRI.  At least free for me.  We all pay for it one way or another.  Thus is the nature of FREE=MORE.  It doesn't get any better than that.  After making sure I didn't have any metal on me I entered the MRI suite for my MRI.  Why can't you take metal into an MRI?  That's why.  

I took the MRI with no problem.  It had a larger diameter than older models.  Unlike Grunt Doc, I didn't feel the least bit claustrophobic.  I almost fell asleep in a state of complete relaxation.   Within minutes of completion, I headed to the radiology department to get my first glimpse of what turned out to be a posterior labral tear.  I have no idea how my labrum tore.    Here's a screen shot of my shoulder MRI showing my posterior labral tear and paralabral cyst formation.  It's no wonder my shoulder has been hurting for so many months.  I also apparently had rotator cuff tendinitis/tendinosis without tear.

With this result in hand, I decided to officially schedule an actual office appointment with the surgeon.  I picked a day I was actually working so I could just head down the hallway to get things done.  It was a 1 PM appointment for the following Monday.  I showed up several minutes early to complete the new patient paperwork.

Do you ever wonder why all those questions are asked on the new patient documentation, especially why an orthopaedic surgeon is asking you if you have any problems with nasal drainage?  They may tell it's for thoroughness.  It's not.   It's to make sure you fill out all their paperwork so it complies for the highest possible billable code for a new patient appointment in the office.  You can read all about the medical billing and coding requirements and even get your own quick reference bedside coding card if you'd like. With that PMFSH and complete 10 point  review of systems performed by you, the patient, they can now bill the highest level new patient clinic E&M code.

So I showed up and played along.  I filled out the paperwork.  1 PM came and went.  Four or five people checked in after me.   Three people were called in before me.  I'm not sure if they all had 1 PM appointments or not.  1:15 pm came and went.  I got paged about a new hospital admission in the emergency department.  I told them to park them there for awhile or send them to the floor and I would see them when I had time.  If you ever wonder why it's taking so long for your physician to show up and evaluate you, it might just be that they themselves are at the doctor's office also waiting to be evaluated.

Twenty minutes after my appointment I was taken back to a room where the nurse took my vitals asked me a few questions and then I sat again.  Ten minutes passed.  Twenty minutes passed.  Then the nurse poked her head into the room.  I explained that I had a patient I needed to go see and if the surgeon was unable to make it to their appointment, I could always reschedule when it was more convenient for them.

The nurse apologized and indicated that the physician was called away.  Funny stuff.  I know what that means.  It's code for I don't know where the doctor is.  I indicated that I was perfectly OK rescheduling because I know how things are.   I was then offered the services of the nurse practitioner.

Talk about an awkward position to be put in. 

Nurse:  If you don't mind we have the nurse practitioner here now who could see you immediately and discuss the options.

Happy:  That's OK.  Dr Ortho and I looked at the films together this weekend in the doctor's lounge and indicated he thought I needed an injection.

Nurse:  Our nurse practitioner has done many injections.  She is quite qualified to provide that for you.

Happy:  That's OK.  Dr Ortho also indicated he was going to perform some bedside maneuvers on my shoulder to document the stability of my joint.

Nurse:  Our nurse practitioner has been trained to do those as well.

Happy:  You know what.  If Dr Ortho is not available, I am quite happy rescheduling when he is.  We have already discussed my case and he is well up to speed on the details and specifics.

Here I am a medical physician who has discussed my case  and reviewed the films together in the doctor's lounge with the orthopaedic surgeon and the office nurse, with good intentions, was trying to push the services of their nurse practitioner my way.  No offense to nurse practitioners, but I made an appointment to be seen by an orthopaedic surgeon, not a nurse with  generalized practitioner training who has received an unknown and undocumented amount of on the job training.   That might go over well with a public that accepts health care at face value, but it's not OK with me.

I signed up for and  expect to get the expertise of an orthopaedic surgeon, not a nurse  with general practitioner training, who, for all I know could have been the best pediatric lactation specialist ever trained, on the job, three weeks prior.  Nurse practitioners must be trained on the job, whatever that job may be, because the length and intensity of their formal education is insufficient to practice any independent scope  similar to medical school and residency trained physicians.

They could be the best pediatric nurse practitioner one week and be doing post op checks on a craniotomy patient the next.   I'm not about to ask for the resume of the nurse who has decided to pursue additional broad training in practitioner school.  I asked for a consultation with an orthopaedic surgeon.  I expect an orthopaedic surgeon's opinion.  It's not about getting the injection.  Heck, I could give my self the injection.   It's about getting an orthopaedic surgeon's evaluation and medical opinion.

Remarkably, he showed up within minutes after I suggested to the RN that  we reschedule my visit for a time more convenient for him.  He did his beside evaluation, manipulated my shoulder to clarify its stability, talked about options expectations and prognosis and then numbed up my skin with some topical spray anesthetic.  He then proceeded with a 10cc intraarticular injection of steroid and anesthetic.  He told me, for a few days,  my arm would feel like someone punched it.  He told me not to do any therapy for 3-4 weeks.

The injection itself was a combination of pain and pressure.  It wasn't horrible.  Just uncomfortable.  Less than a minute later and the procedure was complete.  I had almost immediate relief of pain and for the first 4-5 hours after injection for my posterior labral tear, I had no pain at all.  He was right, however.  Over the next several days I felt a soreness, not where my posterior pain usually was, but superior, over my AC joint, where the injection was administered.  During this time I had absolutely no pain posteriorly where my labrum had been torn.

I am now 20 days out from that appointment and I am happy to report that I continue to have no pain anywhere in my shoulder, except with motions involving extreme posterior extension of my shoulder joint.  I am hoping with post injection rest and time for my shoulder to heal without constant inflammation that I can avoid surgery, which, If I need, will definitely be done this year, when my total out of pocket expenses will be zero.

How much money has all this cost my insurance company on my self referred evaluation and management of my posterior labral tear?  The following are all the expenses associated with my work up of my shoulder pain, including both the charges and the actual allowable charge after run through my Blue Cross Blue Shield insurance.  While I can't say anything about  hospital costs, the hospital charges are quite remarkable as you shall see:

1. PHYSICAL THERAPY SERVICES: Initial visit of physical therapy, seven follow up physical therapy visits, six E-Stim sessions, two ultrasound treatments to my shoulder and the cocktail of steroid cream used for the ultrasound therapy  
1. Hospital Charge: $1,799.00
2. Allowable Charge: $1,241.31
2. MRI SHOULDER
1. Hospital Charge: $2,662
2. Allowable Charge: $1,836.78
3. RADIOLOGIST FEE FOR MRI 
1. Radiologist Charge:  $256
2. Allowable Charge: $130.50
4.  ORTHOPAEDIC SURGEON
1. Orthopaedic Charge: $355
1. Injection ("Surgery"): $165
2. Drugs (steroid/anesthetic): $20
3. Office visit: $170
2. Allowable Charge: $264.10
1. Injection ("Surgery"): $111.06
2. Drugs (steroid/anesthetic/supplies): $3.03
3. Office visit: $150.01

What were my total charges for the evaluation and management of my many months of shoulder pain?

Total charges:  $5,072

Total allowable charges: $3,472.69

My Blue Cross Blue Shield paid 68% of the billable charges.  Medicare probably pays less than 1/2 this amount, or $1,700 and Medicaid probably pays 1/2 of Medicare, or $900. Hospitals cannot survive on Medicaid and and hospital profit margins from Medicare have been negative for a decade.  

We, as private citizens in the open insurance market are essentially subsidizing the Medicare/Medicaid population for their smorgasbord of undervalued, centralized government pricing and Ponzi scheme. If it was not for us, the private citizens of America putting our hard working insurance premiums to work, while our employers divert thousand of dollars in  wages to pay for our health insurance  benefits, our hospitals would simply close.

So America, it's time you sent a thank you to your employer for their help in keeping your hospital alive and well. Without their premium support, you'd be traveling 60 miles for the nearest hospital, like our vets do. And I'm not sure you're ready for that.