Gail Austin Cooney, MD FAAHPM

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Posts by Gail Austin Cooney, MD FAAHPM

Driving Miss Daisy

You’ve all been there – the elderly couple shuffles into your office, peering through oversize glasses, slightly disoriented but helping each other out. Did you ever stop to think how they got to your office? They almost certainly drove – but should they? Shouldn’t it be their children’s job to tell them to stop?? Focus groups have shown that it’s the physician they look to for guidance (sigh).

Luckily, there are excellent resources to guide you in evaluating driving impairment and to let you know what the laws are in your state. Google “AMA older driver safety” for a wealth of information. It’s free and you don’t have to be an AMA member to access it. There are even disease-specific recommendations from areas as diverse as ophthalmology, cardiology, and neurology. The AMA also has an ethical opinion on impaired drivers and charges the physician with recommending driving restrictions and, if needed, reporting impaired drivers to the Department of Motor Vehicles (DMV).

Dr. Karen Cross recommends a 6-step approach. (1) Identify patients at risk of impaired driving; (2) find out if the patient is still driving; (3) assess their driving skills; (4) make recommendations with referral for a driving evaluation – try for resources; (5) counsel the patient about transportation alternatives; and (6) if all else fails, report the driver to the DMV.

A little more on identifying patients at risk of impaired driving. Driving requires vision, both peripheral and focal. It requires physical activity – from opening the car door to moving one’s foot from the gas to the brake. Reaction time is also important, along with memory and the ability to concentrate, especially when distracted. Many of these skills can be evaluated in the office or home setting. A driving evaluation may be useful when there is conflict over the patient’s abilities. Unfortunately, these are not covered by Medicare or most insurers and can be expensive.

Restricting a patient’s driving can be life altering, resulting in depression, social isolation, and impaired self-esteem. There’s even an increased risk of long-term-care placement if an elderly person can no longer drive to meet their daily needs. On the other hand, there is the risk of injury to themselves or others. It is a physician’s responsibility to make the tough call and recommend driving restrictions when they are needed. Remember to check the AMA website for state-specific tools to support your recommendations.

Safe driving!

NEJM Study Shows Palliative Care Extends Life

Most of you have already seen the study released yesterday in the New England Journal of Medicine and I suspect that those of you who work in palliative medicine were not at all surprised by the results: patients who received palliative care along with standard oncology treatment for advanced lung cancer not only had a higher quality of life, but lived three months longer, as well. Isn’t that what we’ve been saying all along?

I have personal experience that supports their conclusions. When I was diagnosed with advanced ovarian cancer in 2008, I relied on a program of palliative care to enable me to tolerate the toxic intraperitoneal chemotherapy that was recommended. I was determined to get ALL of my treatments, WHEN they were scheduled, in order to give myself the best chance of responding. I sought out aggressive symptom management, controlling the pain and nausea so that I could be ready for the next round of treatment. I saw an oncology counselor and set up a website to coordinate meals for my family and me. I prayed. My friends prayed. Friends of friends prayed. I used acupuncture, initially to help with the nausea but later, just because it made me feel better. Three Reiki masters came to my home weekly to keep my energy positive.

And I stayed on schedule! I had chemotherapy the day before Thanksgiving (only because they were closed on Thanksgiving and Thursday was my “usual” day). I finished my last treatment on Christmas Eve. I was determined to do this and palliative care made it possible. With an “n” of one, I’m not a randomized trial, but I did better than those around me. And, I’m still here two years later to marvel at my survival.

But now there IS a randomized trial!

151 patients with newly diagnosed, metastatic non-small-cell lung cancer were randomly assigned to receive either early palliative care integrated with standard oncology care or standard oncology care alone. The primary outcome was the change in quality of life at 12 weeks, assessed by the Functional Assessment of Cancer Therapy-Lung (FACT-L) and the Hospital Anxiety and Depression Scale. Data on end-of-life care were collected from electronic medical records.

Patients who received concurrent palliative care had a better quality of life than did patients who received standard care alone (P = 0.03). They also had fewer depressive symptoms (P = 0.01). At the end-of-life, the palliative care group had fewer aggressive treatments (aggressive care was defined as receiving any of the following: chemotherapy within 14 days of death, no hospice care, or admission to hospice less than 3 days before death) (P = 0.05). Despite this, the patients who received concurrent palliative care from the time of diagnosis lived longer – almost 3 months longer (ll.6 months vs. 8.9 months, P = 0.02).

This study confirms the importance of palliative care begun at the time a serious illness is diagnosed, enabling patients to live better AND to live longer. Great news for patients and for the field of palliative care.

Is Your Signature Legible?

The first piece of education reviews the basic Center for Medicare & Medicaid Services (CMS) requirements for authentication of services provided or ordered. When CMS reviewed numerous examples of CERT signature denials, they found in almost every instance that the documentation was acceptable. Services were denied because of one of four “not acceptable” signature reasons, including

1. Illegible, unrecognizable handwritten signature or initials
2. Unsigned “typewritten” progress notes with a typed name only
3. Unverified or unauthorized electronic signatures
4. No indication of the rendering physician/practitioner

The Palmetto GBA Medical Directors strongly encourage the following improvements

1. Be sure a handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation
2. Records should clearly indicate they have been “electronically signed by” and include a date/time, including verbiage that makes this clear
3. Establish a protocol to ensure valid signatures are affixed to every order, record, or report within a reasonable time frame (i.e., customarily 48-72 hour after the encounter – but certainly before the claim is submitted to CMS for payment)

Additional information about the CERT program is available on the Palmetto GBA website under the CERT link. This focus is likely to apply to other intermediaries soon, so watch for additional educational updates and start looking into your current processes.

“Create an organization that’s so effective that you can’t afford not to belong.”

That’s the guiding principle of the Council for Medical Specialty Societies (CMSS) and AAHPM is their newest member! This month, Laura Davis, AAHPM Director of Marketing and Membership, and I represented AAHPM at the CMSS spring meeting in Washington DC.

What is CMSS and why did AAHPM leadership decide that it was important to participate? CMSS represents the needs of physician specialists and subspecialists in American health care. And, with complicated issues like the medical home and graduate medical education slots on the table, they represent an important voice. I liked their two overarching goals – (1) to create a culture of performance improvement and (2) to model professional and ethical medical practice. And they’re taking action. During the April meeting, CMSS approved a code for ethical interactions with health-care companies.

Michael Hash, Senior Advisor HHS Office of Health Reform and liaison to the White House Office of Health Reform, talked to the Council about the recent health reform legislations. He emphasized that Medicare and Medicaid will both focus on the subset of patients with multiple advanced chronic diseases. Hello?? Did someone say “Palliative Medicine?” On the GME issue, he did not expect any increase in the number of “slots”; instead, legislation is focusing on loans, loan forgiveness, and National Health Service programs. And last, he asked that physicians actively support Don Berwick’s nomination as director of CMSS – look for legislative action alerts!

Tom Nasca MD, CEO of ACGME spoke next about upcoming ACGME recommendations regarding resident duty hours. He strongly urged physicians to support the ACGME proposals, noting that, if the medical profession fails to act, someone else (i.e., the federal government) will do it for us.

Two panel discussions presented issues regarding the Patient Centered Medical Home (PCMU), the meaningful use (MU) of health information technology (HIT) – it’s Washington, loads of acronyms – and their intersection. I found a couple of useful take-home messages. First, current EMR (electronic medical records) are built to coordinate billing, not patient care. It’s SO true, but somehow I had missed that point before – I can be slow. Second, a new EMR needs to collect data on practice improvement, because performance measures are expected to be integral to proposed health care changes. And third, your EMR should support care coordination, the core principle of the PCMH model.

No one is quite sure what the PCMH model will look like, but it’s expected to follow NCQA guidelines. There’s talk of the “medical neighborhood” that includes specialists and subspecialists. And it’s likely that we’ll see non-physician providers (NPs and Pas) as PCMH practitioners soon. AAHPM needs to continue active discussion of how HPM physicians might fit into the PCMH model – Chad Collas and the Public Policy Committee are already at work.

Membership in CMSS is just another example of how AAHPM is working to meet members’ needs in a changing health care environment! Stay tuned for more. And leave your comments on these issues – we need to hear from you!!

Exhibit Hall Action

Smiling Guests at the Exhibit Hall

This is a belated entry – I couldn’t get in to post last night, but still wanted everyone to know about the great action in the AAHPM exhibit hall!

It’s 9:20 and I’m just returning to my hotel room after a long and exciting day at the AAHPM Annual Assembly. I missed the pre-conferences but the word is that they were fabulous! The down side of being a board member is having to miss the pre-cons – and there’s SO MUCH that I need to learn – especially as I’m preparing for my Board exams in the fall. I grabbed a brochure for the August board review course in Chicago.

At 5:30, the exhibit hall opened – WOW! It’s bigger and better than ever. I had the privilege of giving the poster prize to Dr. Jillian Gustin from Ohio State University. Go Buckeyes! Stop by and check out her research on symptoms of depression in terminally ill parents with young children.

Find some time to visit!

Gail Austin Cooney MD, Hospice of Palm Beach County, West Palm Beach, FL