National Guideline Clearinghouse Goes Kaput

Although the practice of medicine has existed for thousands of years, it substantially improved with the implementation of the scientific method. Experiments and research studies improved diagnosis and treatment. Now so much information is published that no person can read everything unless, possibly, it’s limited to an extremely narrow subspecialty.  In addition, different studies can come up with opposing results, and it can be difficult to make sense of all the available information.

To remedy that, various groups have published guidelines to help clinicians decide what to do. For example, new guidelines for high blood pressure were recently published. The American Diabetes Association just updated their guidelines for Standards of Medical Care in Diabetes.

So how does one find out about existing guidelines, other than doing a web search or coming across it in a journal? Well in 1998 the National Guideline Clearinghouse was created. It formed a collection of guidelines that met minimum quality criteria. By June 2018 there were more than 2000 guidelines listed that could be searched by specialty. In July of 2018 all of that information became unavailable on the website because of federal government budget cuts.

The website was originally created by the Agency for Healthcare Research and Quality (AHRQ), in partnership with the American Medical Association (AMA) and the American Association of Health Plans (now America Health Insurance Plans).

In the last year of operation, the National Guideline Clearinghouse’s budget was about $1.2 million dollars. This is only about 1% of the money spent globally on developing guidelines, and an even much lower percentage of the cost of medical care. The guidelines can improve care and save money, but only if people can find them. Both my company’s electronic health record and my county medical society’s website have the National Clearinghouse Guidelines integrated to reach them with a click. I’m sure we’re not the only ones who routinely used it.

Perhaps a better repository can and will be built, but in the meantime I think the government should fund the National Guideline Clearinghouse and bring it back online.  This was not a case of trimming fat from the national budget, but a self-inflicted stroke where the government cut off the blood flow (money) to a portion of our collective brain. We’re the worse for it.

Trying to Destroy Healthcare the Ostrich Way

Copyright: <a href=''>andreykuzmin / 123RF Stock Photo</a>Ostriches reportedly stick their heads in a hole if they see something they fear. If they can’t see it, then it must have gone away. President Trump, with most republicans lawmakers going along, is trying that same tactic on the public. Despite 7 years of promises, and multiple attempts, Republicans have been unsuccessful overturning the Affordable Care Act, otherwise know as ObamaCare. So Trump has been doing everything he can to destroy it, with the hopes that it will wither and die, then he can blame Democrats on it’s demise, claiming it was bad legislation. This despite not having a good alternative.

One of the efforts have been to keep people from signing up for coverage for next year. The Trump administration has cut the advertising budget by 90%, shortened the enrollment window, and will close the site on some Sundays for, “maintenance.” They figure that if people can’t see it, they will think it must not be there.

Well sign up just started. If you don’t otherwise have coverage, such as through work, sign up right away, while you still can.  You must sign up by 12/15/17. Don’t wait until the last minute as you might not be able to get on the site. Don’t be scared off by reports of premiums going up. Although true, subsidies also go up per the law, and it costs nothing to find out what it would cost for coverage. Go to

Remote Globe Puppy


The New York times just ran a story about how Mongolia uses a system for their mail where each address consists of three words. A clever British start-up company What3Words divided a map of the world into 57 trillion pieces, each 9 square meters (about 10 x 10 feet), and assigned a 3 word combination to each one.

I checked the address of my office, and it’s crowned.tamed.raced. Given that each address takes up such a small area, I honed in on the map to where the actual rooms in my building are. Here are some of the address I came up with: remote.globe.puppy, patio.thin.ropes, living.quit.exit, castle.lofts.roses, famous.learns.cheek, and minds.agent.former.

I would say that as a geriatrician, living.quit.exit is a pretty good description of what I do, but from a marketing perspective, I’d have to go with remote.globe.puppy.

An ICD-9 Story

Medical billing and epidemiology relies on a classification of diseases maintained by the World Health Organization. On the first of October, 2015, we will transition from ICD-9 to ICD-10, a major change that increases the number of available diagnoses from some 17,000 codes up to more than 155,000. In a strange cosmic twist, that’s the same day that most retails need to install readers for credit cards with chips or be liable for bad purchases.

With that in mind, I present a short story in ICD-9, with a translation into English.

It was E900.0. That, combined with E904.1 and E904.2, not to mention V69.4, is what led to 780.2. I admit it, I have V69.0 and V69.1. I usually sleep well, but that night was different, thanks to 780.55 due to 780.92. That morning I understandably drank 969.7, leading to 785.1. During E924.2 while E013.0 I felt 780.4. Stepping out I had 368.45 before I 780.2.When I was V49.89 after my E884.9. I had a 784.0, as if I had a 305.00. I used my E011.1 to call work to say I’d be late and hoped to avoid V62.1. He greeted me with a 784.42 indicating 300.4.

Last year I V49.89. The flights are arduous, subjected to E918 or being in V01.9 with a 780.92 E979.6 at E902.0. After landing I’m 780.79 due to V69.4 and 780.55, leading to excessive 786.09.

I was in 309.29. At least, thank to the ubiquity of E849.6, I didn’t have to suffer from 292.0.

If you think this makes for 315.00 and is a 729.1 to read, just wait for ICD 10! Ever see a V91.07XA?!

It was too hot. That, combined with lack of food and water, not to mention lack of sleep, is what led to my fainting. I admit it, I don’t exercise or eat right. I usually sleep well, but that night was different, thanks to interrupted sleep from my son’s crying all night. That morning I understandably drank one too many cups of coffee, leading my heart to skip a beat. During a hot shower I felt lightheaded. Stepping out my vision narrowed before I passed out. I awakened after my fall to the floor. I had a headache, as if I had a hangover. I grabbed my cellphone to call my work to say I’d be late and hoped I wouldn’t be in trouble with the boss. He greeted me with an edge to his voice, indicating he was wasn’t completely happy.

Last year I traveled to foreign countries. The flights are arduous, subjected to being squeezed in with other passengers, or being next to a crying, germy child at altitude. After landing I’m worn out due to lack of sleep and jet lag, leading to excessive yawning.

I was in culture shock. At least, thank to the ubiquity of vendors, I didn’t have to suffer from caffeine withdrawal.

If you think reading this is difficult and is a pain in the butt to read, just wait for ICD 10. Ever see a burn due to water-skis on fire?!

Asinine Associations

As I previously wrote, when physicians place orders, they have to associate diagnoses. This is becoming even more painful as we move towards ICD-10, of which I’ll have more to say later.

I’m sure this was an attempt by the government to save money, but in the vast majority of cases the ordering physician has no secondary gain, and they order the test because they think it’s the right thing to do. I can understand it for some expensive tests or procedures, but many are just plain obvious.

I think lawmakers should have a taste of their own medicine. When they need office supplies, they should have to give a reason. Here, I’ll help them out with a few items to help them understand how it works:

StaplesTo attach separate pieces of paper.

NotepadTo write down information.

PenTo apply in conjunction with a notepad to convey information.

ChairTo help counteract gravity to prevent leg and back pain and fatigue.

Laser Printer TonerTo print out things using a laser printer.

Light BulbTo counteract darkness.

Sesame Chicken


I often suggest my patients use smart phone apps to help them with their diet, in particular Lose It! or MyFitnessPal. Both progams have the ability to scan a bar code of a food item, which will then show the amount of calories, protein, fat, carbohydrates, etc for a given portion size. Not having any food in my exam rooms, I grabbed the box of tissues to show how to scan the bar code. Lose It! identified it as Sesame Chicken!

A High Tech Call Schedule


Typical of many physicians, I have to take turns being on call. This mostly involves taking calls in the evening, at night, and on weekends for my patients, or those in my call group. I belong in a group with 6 other internal medicine doctors. We no longer have to go to the hospital to admit patients, since that is now done by dedicated hospitalists, but may answer calls about patients in our practice that show up in the emergency room, or are in a nursing home and having issues, or have significantly abnormal laboratory results that come back after hours.

My group takes call a week at a time, and the schedule is made each December for the following year. Each person in the call group submits a list of days they do not want to be on call, and the person making the schedule does their best to accommodate everyone. If someone needed to make subsequent changes, they would need to check the schedule and try and find someone to switch, or others would take their call in the event of a personal or family emergency. The call schedule was 12 pages of a printed calendar with the call person written for each day.

Last year the person making our schedules retired and I took over the duty, with the agreement that the schedule would be computer based. I created a Google Calendar, for the call schedule. I assigned each person their own color and created the schedule, after working it out on paper first to make sure I accommodated preferences, made the schedule as fair as possible in terms of amount of call and holiday coverage, and trying to spread out call.


I sent out invitations through Google Calendar. Now everyone in the call group can see their schedule on their computer. They can also use an app on their phone, as shown below. If changes need to be made to the schedule they notify me or our office administrator to make changes to the calendar. Everyone in the group then automatically gets the updated version if they check their calendar.


Recently I added a new twist. Having purchased the Amazon Echo, I added my Google Calendar to the app. Now I can ask Alexa what’s on my schedule, and she will read who is on call!



Medicare Payment Formula Finally Changed – Win or Loss?


Congress passed a  law in 1977 linking Medicare payments for physician services to growth in the economy.  Because it failed to take into account inflation and other factors, Congress has had to act 17 times to prevents cuts to physician pay under the sustainable growth rate (SGR) formula. This year physicians were set to get a 21% pay cut this year. This created a lot of stress and uncertainty for physicians, and caused some physicians to stop accepting Medicare patients.

The Senate recently voted to repeal this formula, 92 to 8. The bill was already approved by the House, and now President Obama has signed the bill.

That sounds like a great triumph for physicians. Although this may prompt some to pull out their imaginary violins in mock sympathy, I’m not so sure it will turn out to be such a great deal for physicians, which actually only consumes 12% of the Medicare budget.

The bill freezes the current rates, then increases them 0.5% a year from 2016 to 2019. For 2020 through 2025 there is no increase, and from 2026 onwards it increases by 0.75% per year. That is far below the current rate of inflation, and there is no provision if inflation gets worse than the currently low rate. That effectively means a real loss every year into the indefinite future.

There is a provision to transition payments to reward physicians for quality, rather than quantity. That is good in theory, but we’ll have to see how that works out in practice. Quality healthcare is very difficult to measure, and there is a risk that quality will be defined based on what’s easy to measure, and that will lead to physicians and other healthcare providers to concentrate on what they are rewarded to do, and not what may be in patients’ best interest. I hope I’m wrong.

Epic SmartPhrases

If you do not use the electronic medical record Epic Hyperspace, this article is probably of no interest to you.

I previously wrote that I have done a lot of customizations to Epic. In this post I’ll explain how I use SmartPhrases. These are text, ranging from one word, to multiple pages of material, generated by typing the name of the SmartPhrase, preceded by a period.

My approach is to be modular in creating SmartPhrases, as I’ll demonstrate below. I also don’t like to pull in information into my note, such as past history, labs, etc. as the information is already in Epic and it just clutters up the note (I do bring in much of the information for physicals because I think that’s the one time it’s useful to have everything in one note. If acting as a specialist and doing a consultation I might do the same.) Unless I’m doing a physical, which has its own scripts, my baseline script is .soap which looks like this: Continue reading “Epic SmartPhrases”

Pierce County Medical Society Website Launch

Pierce County Medical Society LogoI’m proud to announce that today the Pierce County Medical Society (PCMS) went live with a newly redone website. I’ve been working on it for over a year.

There is a lot to see on the site. I’ve created a video that gives a tour of the site. It’s aimed at members, who see a link after logging on, but most of the content is useful for the general public, including how to use the Physician Search section to find a doctor in Pierce County.