| 4/1/2014 | Problem-Based Charting mandatory for hospital notes (with penalties) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Sent To | Stanford Internal Medicine Residents | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Context |
The hospital administration has been experimenting with and trying to push out
a measure to have residents write their patient notes in a more rigid and structured
manner. For the most part, there has mostly been backlash from the residents
in having to change their methods and wrestle with more computer systems.
To further augment broad hospital goals, they recently started "Clinical Documentation Specialists" that (often annoyingly) pester residents to revise the way they phrase their patient notes to make them sound more ill. |
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| Message |
Hi all, I've been circumstantially involved in providing feedback on hospital documentation and EMR use based on various projects, and wanted to alert you to important changes. Some of you may already be familiar with this Problem-Based Charting concept that's being used at [another hospital] and has been piloted in the ICU. This initiative is being pushed from the top administration down to residents to resolve issues with grossly inconsistent and inadequate care documentation. Based on the perceived success in the ICU, they're pushing even harder now, making this a mandatory approach to patient notes on *all* hospital services. They are ratcheting it up even further by no longer allowing *any* free-text in your Assessment and Plans. All of your diagnoses, differentials, and interventions in your new PBCharting style A&Ps will have to be selected from drop-down lists of administration pre-approved ICD10 and CPT codes. The above apparently addresses inconsistent documentation of illness and severity resulting in poor Observed:Expected outcome scores, and overall improves the efficiency of subsequent hospital billing, making this a priority for the administration. To help ease the transition, any non-conforming notes you write will result in daily pages from Clinical Documentation Specialists to talk you through how to retroactively correct all notes. To ensure motivation and compliance that would otherwise result in lost revenue from unbillable notes, residents who do not properly use the system or work with with the Documentation Specialists will have their computer accounts disabled after a week. You will have to ask your attending to write notes for you until all of your prior notes are corrected or further disciplinary action is taken. I copied below a draft of the hospital's full procedure guideline on how this will be rolled out and what you can do about it, http://www.stanford.edu/~jonc101/infoReport.htm Jonathan |
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| 4/1/2013 | Disusering extending to Hospital Computer Accounts unless *Monthly* online training completed Re: disusering today | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Sent To | Stanford Internal Medicine Residents | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Context |
As residents and hospital employees, we have to complete annual online training modules, which can literally take hours to click through to superficially cover assorted topics on administration, documentation, privacy, safety measures, etc.
Several days prior, some unexplained debacle occurred where hundreds of residents lost their computer account access to one of the hospitals, as per this e-mail excerpt from one of the chiefs: The [hospital] just got a little crazier. There are many residents who have been disusered (apparently 900) because of incomplete [online] training or some related problem. This means you can't get onto [the computer system], write notes, put in orders, etc. |
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| Message |
Hi all,
After much aggravation trying to get my [computer] account back online (despite having properly completed the [online] training a while ago), I got one of the managers from the Compliance Office on the phone to figure out what is going on. Apparently this is part of a measure to strengthen enforcement against poor compliance with professional behaviors. Issues they cited include running around with patient (sign-out) notes in our pockets, leaving them in unlocked rooms or lingering at public printers, leaving public computers logged in, sending patient information through unencrypted e-mail, as well as consistently flagrant disregard for basic hand hygiene, contact isolation, and sterile technique measures. Management's solution to this, which annoyingly was not properly communicated beforehand, is to require us to complete the online training modules that address these issues, and to do so *Monthy* as a frequent reminder (this is why many of us got our accounts "expired" even though we thought we completed online training >1 month ago). This method will be extended to disabling of our [other hospital] accounts this week unless we complete the [other] training modules monthly as well. Furthermore, the online modules will be modified such that they cannot just be "clicked through," but will require a minimum number of hours of active use to count for credit (if you've ever done an online driver's training course, it's something like that). Linked below is a copy of a report they provided me with statistics on the frequency of the non-compliance behaviors. They plan to keep these measures in place until compliance rates across all residents are documented above 90% in all categories. http://www.stanford.edu/~jonc101/infoReport.htm Jonathan |
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| 4/1/2012 | Hospital cracking down on copied notes. Will deduct resident salaries if not (retroactively) corrected! | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Sent To | Stanford Internal Medicine Residents | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Context |
As medical residents, much of our day is often spent writing notes describing the daily
care plan for our patients. This can be a very tedious task, and when you have an electronic
medical record system, it's pretty darn easy to just copy-and-paste prior notes.
A few weeks prior, a mini e-mail flame war was kindled amongst the residents, regarding copying each other's notes without credit, and recycling daily notes and plans for days without updates. In response to those, I previously left a reply of:
"Plagiarism is the sincerest form of flattery... |
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| Message |
Hi all, You'll probably hear about this via official channels soon, but wanted to give you a heads up on incoming issues. Giving credit to each other for copied notes was all fun and games, but unfortunately our discussion has opened up another whole Pandora's box. The hospital administration got wind of our prior e-mail thread and they had someone call me with questions related to a current investigation into documentation deficiencies. Apparently, when we copy our daily progress notes, particularly the assessment and plan, this has bigger implications towards hospital billing. The hospital cannot bill insurance companies for daily notes if a *critical assessment and plan* is not done by an MD. When the A&P is straight up copy-pasted from the prior day, the insurance companies are rejecting billing, arguing that this represents no documentable proof that an MD provided any critical thought into the patient's management. Because "asking nicely" clearly has not (and most likely will not) change these practice patterns, the administrator I talked to intimated that they will be instituting much stricter enforcement measures. Specifically, for any daily note that insurance refuses to pay for, the hospital's resultant lost revenue will be taken out of the authoring resident's salary! Furthermore, to recoup prior losses, the hospital will require residents to retroactively update any deficient notes from the past year to allow for proper billing, lest the same losses will be extracted from the offending residents' salaries. If you want to know more, they provided me a report of statistics illustrating the pervasiveness of this type of documentation issue and the memorandum expressing the hospital administration's position and plans (linked below). http://www.stanford.edu/~jonc101/infoReport.htm Jonathan H. Chen |
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| 4/1/2011 | ACGME Mandates 1-year Addition to all Residency Training Programs to Accommodate Work Hour Restrictions | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Sent To | UC Irvine 4th Year Medical Students | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Context | 4th year students about to move on to their first year of medical residency training within a few months. A lot of buzz and controversy over a new national mandate from the ACGME (accreditation board that oversees all medical residency training programs) that will enforce limits on how many consecutive hours a resident can work. Many training programs balked at these "duty hour restrictions," as they often relied on having residents work 30+ hour shifts at a time and >100 hours per week. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Message |
Hi all, You'll probably be hearing a lot more about this in the coming days if you haven't already. Due to all of the controversy over the upcoming intern work hour restrictions, many residency programs have been pushing to extend their training programs to ensure they have enough house staff to cover their service needs, and ostensibly to ensure we are getting sufficient training by the end of our residencies. Rather than this occurring erratically and unfairly across individual programs, the ACGME has decided to unilaterally mandate that ALL residency training programs (starting with our groups this July) be extended by an extra year. This will effectively require us all to go through an extra intern / pre-lim year. I copied the full report at the link below. You should definitely review it to see how these changes will be impacting us. http://www.ics.uci.edu/~chenjh/infoReport.htm Jonathan |
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| 4/1/2011 | Extra tax liabilities for MSTPs? Fw: Mistakes in 1098T reporting | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Sent To | Students of the UC Irvine MD/PhD Program | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Context | As part of MSTP (Medical Scientist Training Program), our MD and PhD training tuition is paid for (we just have to make a non-refundable contribution in the form of the best year's of our lives). This includes an additional stipend we're essentially paid as a salary for living expenses, though it does not technically come through as a W-2, just a straight check that we get from the University, which we have to report for income taxes ourselves. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Message |
Hi all, While doing some last minute tax filing preparations, I was digging through www.1098T.com The critical implication is that our tax liability is almost double what I thought it was. Even more so, as I talked with an accountant for help this year since my tax situation is getting more complex (baby, home, partnership in LLC), he pointed out that for all the years past that I did not account for those amounts, I'm going to be liable and will have to retroactively pay for all of them, plus interest and penalties. This is unavoidable at this point because audits are coming down on everyone receiving training grants this year. This is because the state is desperately tracking down any source of lost revenue it can find amidst the current budget crisis. I made a copy of the full report on the situation at the link below: http://www.ics.uci.edu/~chenjh/infoReport.htm Jonathan From: UCI TRA Sent: Wednesday, February 23, 2011 10:15 AM To: Chen, Jonathan Subject: Re: Mistakes in 1098T reporting Dear Jonathan: For the Box 5 ("Scholarships or grants") amount, IRS rules specify that "...institutions must report the aggregate amount of scholarships or grants received for an individual's costs of attendance that the institution administered and processed during the calendar year." The Box 5 amount therefore includes registration fee payments, not just stipend checks. The amounts you are disputing below are registration fee payments credited to your student account each term. Following your fee payment, the remainder of your financial aid award was disbursed as check. For example, for Spring 2010, your MdPhd Stipend award was $X,XXX.00. Of this amount, you received $X,XXX.50 in your student account to pay registration fees on 02/23/2010, and $X,XXX.50 in EFT/check 7720585 on 03/22/2010. I have verified all of the records listed online as belonging to your student account. There has been no confusion with another student's records, and no error in 1098-T reporting. On 2/22/2011 7:02 PM, Jonathan H. Chen wrote: Hi, I was just reviewing my 1098T form online, provided from UCI. My (medical school) ID is ... and name is Jonathan Haelin Chen. Box 5 (Scholarships and Grants) is reporting $XX,XXX which includes several installments that are not accurate. On the page 4 Financial Detail page, the following MdPhD Stipend amounts are correct in that I received them: 1/1/2010 $X,XXX.50 3/22/2010 $X,XXX.50 6/23/2010 $X,XXX.50 8/20/2010 $X,XXX.00 The following amounts are incorrect, I never received them. It appears that someone else's record were mixed in with mine, which is apparent since there are multiple amounts with the same description (e.g., 2 amounts described as "MdPhd Stipend Sprg"). 2/23/2010 $X,XXX.50 5/14/2010 $X,XXX.50 8/11/2010 $X,XXX.50 11/19/2010 $X,XXX.50 Thank you for your attention, Jonathan |
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| 9/22/2010 | Step 2 CS | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Sent To | UC Irvine 4th year Medical Student Class | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Context |
Step 2 CS (Clinical Skills) is one of exams we must pass to complete medical school.
This is a "practical" exam that was recently added as a national requirement, where
you meet several "standardized patients" (i.e., actors) and pretend you're evaluating
and counseling them on random medical concerns. This exam costs over $1000 for the student,
and most students around the nation have to fly out to get to one of only a handful of testing centers.
My message was in response to one of the other students who wrote:
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| Message |
Hi XXX (and anyone else going to take Step 2 CS),
You should tell that Harbor resident to get bent. I'm sure people do fail CS "all the time." A lot like how cars crash on the freeway *all the time!* Just think of all the times you've seen an accident on the freeway! Of course, that's ignoring the other 95+% of cars that pass through completely unscathed. First Aid lists some stats, including that the pass rate for CS is ~96% for US medical students. It's only lower (like 80%) for foreign medical students who have more trouble with English and carrying on an interview. I just quickly crammed some of the material in First Aid CS the night before. It's okay as a general review to get in the mode, but actually, there was not much overlap with the cases I got at the real thing. You really will just have to rely on your general knowledge of medicine that we all already have. Which is fine, since it's really more about your ability to illicit a relevant history and physical exam and then summarizing your impressions. If anything, I felt the biggest challenge was time management. You only get 15 minutes per encounter, and I found myself running out of time on several. There's 10 minutes afterwards to write a note on each patient, which should be enough time, but the other annoyance I had was that they limit the word count you can enter. As you may have noticed from this e-mail, I can be pretty verbose, which gave me grief as I kept hitting the limit while writing out the history (though much of it was filled with boilerplate negative review or systems, etc.). In any case, a lot of the evaluation is just based on a checklist of BS items like making eye contact, introducing yourself, washing your hands, auscultating under the gown, draping the patient, etc. Having said all that, once I find out I failed CS, I'll probably feel pretty dumb. While I'm on this rant, as a thought experiment: If you were considering a diagnostic test that had a 95% pre-test probability of being positive (like say a D-dimer in any chronic hospital patient), the appropriate response should be that the test is an utter waste of time and money. Jonathan |
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| 4/1/2008 | Serious network drive problem | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Sent To | Grad Students and Post-Docs of my Computer Science Research Group | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Context | Computer science research group where essentially all of our work is based on software written on shared network drives. Data center had been having not infrequent issues recently, with sporadic shutdowns, as well as moving our program libraries around. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Message |
Hey guys,
I think we may have a big problem. Some of my programs were doing funny things, and when I traced it back, I realized there was some serious data corruption on the network drive. The effects are subtle, so you may not have realized it, but any code you've checked in or out and any programs you've been running off any code or libraries in the /home/dock tree in the past couple months are almost certainly invalid, which means we all have a ton of development and experiments to do over. I checked with helpdesk to track the timing and origins of these errors and copied their full report to the link below if you want to know more. http://www.ics.uci.edu/~chenjh/infoReport.htm Jonathan |
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| 4/1/2008 | Dropping out of the program | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Sent To | Students of the UC Irvine MD/PhD Training Program | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Context |
In recent months, several students quit the program
(deciding to only continue with the MD, and dropping the PhD).
A demoralizing sign for everyone else.
In the meantime, at recent student retreats, I've been presenting my work on chemistry reaction software that I developed as part of my PhD project. |
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| Message |
Hi all,
I know this may come as a surprise to some of you, and I hate to be the 4th one in so many months, but I've decided to leave the MD/PhD program after much deliberation. I just received an impressive buyout offer from a publisher for my reaction software that makes school seem not so meaningful anymore. I'd like to say I'll miss the school and all of you, but now that I have money in the bank, who are we kidding? If you're interested in more information, I linked below a copy of the press release on the acquisition. http://www.ics.uci.edu/~chenjh/infoReport.htm Jonathan |
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Incidentally, the picture above was drawn by my wife many years ago. It was actually intended to reflect my response to getting to eat good food.