Monday, November 28, 2011

Controlled Substance eRx: Is it live?

According to this Surescripts press release "a select number of certified and audited vendors and their users located in states where EPCS (E-Prescribing of Controlled Substances) is legal" have "begun the initial deployment of EPCS." When this trial period is complete, possibly January 1, EPCS will be made available to all.

Is your eRx live with EPCS yet?

If so, please reveal their identity.

Thursday, November 17, 2011

Forms R Us

I think I'll design a T-shirt or bumper sticker that says:

Will Fill Out Forms
For Free
Any Forms
All forms

I tend to like forensic work, even evaluating workers for risk of violence, at least as much as clinical work, for, among other things, the inherent ability to evade the constant stream of people -- often not the patient, and institutions, who demand that I fill out forms and sign agreements, usually unrelated to my role as physician. 

I can hear the conversation in the human resources department now:

"Do we need this form filled out before we can send the retainer check?"
"Gee, I dunno. What kind of supplier is it?"
"I think he's a doctor."
"A doctor? Don't worry about it. Just tell him he has to fill out. Doctors always fill out whatever form you shove under their noses."

Regardless, yesterday a potential forensic client told me I would have to complete, in addition to the usual W-9, an "Approval" form, and a "Supplier Classification Form" before the local employer (my client) would cut a retainer check for me so we could schedule an independent examination of a worker who may pose a threat of violence.

Approval Form
As far as I can tell the only items I know are my address and phone number on this spreadsheet. I guess they're short-handed in the typing pool. Other items include: "Does this supplier have a relative working for [Company]?" and "Does this supplier h" [?]. My favorite: "What is the reason an existing supplier cannot be used?"

Supplier Classification Form
If you have not seen one of these, it consists only of a bunch of check box items where you indicate whether you are a small business, a large business, a "Service Disabled Veteran Owned Small Business" or any of several others. Since I'm a physician I thought maybe I should check "Small Disadvantaged Business." (I'm not sure which is worse: provider or supplier.)

But this is no joke. If I get it wrong, according to the "PENALTY" section I may face "fine, imprisonment, or both."

So let's look at the whole enchilada. I will be paid a reasonable fee to examine someone who may be dangerous, and who I may make even more dangerous, potentially to me or my family, if he doesn't like my determination. And add to that risk of fine or imprisonment for claiming I'm a small business when in fact a prosecutor might prove that I'm actually a HUBZone Certified Small Business. (I have no idea what that is.)

I think I'll pass.

You might correctly object that it is quite possible that these are well-meaning folk, just trying to make sure they keep out of trouble with all the gumment regulations, and have a physician and his malpractice carrier share the risk if the worker goes postal. That's fine. They -- and the gumment -- can do so to their hearts' content -- without me. Thank you very much.

Thursday, November 10, 2011

Waking Up Is Hard to Do

Inundated with new, and often unproven, biological and psychological treatments for mental disorders whose causes remain mysterious, psychiatrists should welcome any promising treatment. This CME article appearing in the October, 2011 issue of Psychiatric Times describes just such approaches involving treatment of depressive illness by keeping the patient awake all night, followed by sleep phase advance and bright light therapy, with or without initiation of medication.

At first glance you might think you could do this at home with minimal professional support, but a person suffering from major depressive disorder might find it challenging to stay awake all night unassisted. Could a practical nurse provide such a service with minimal training?

For answers to other questions that came to my mind regarding protocols refer to the programs outlined at Chicago Psychiatry Associates Program in Psychiatric Chronotherapy and Columbia University's Light Treatment Center.

  • What signs and symptoms predict greatest likelihood of positive outcome?
  • What contraindications exist?
  • How can staff keep a resistant patient awake?
  • Can stimulant drugs be used to prevent sleep?
  • How can you tell whether the home and family are adequate for the task?
  • How should treatment emergent mood elevation be managed?
  • Are there other risks?
  • Are there risks for those who stay awake with the identified patient?
Is the novel treatment approach ready for prescription by the office-based psychiatrist for use at home, or should we amass more experience in hospital settings?

Thursday, November 3, 2011

What's making more Greeks kill themselves?

According to a piece I heard on NPR a couple days ago suicides are up in Greece. Is this because of reduced availability of psychiatric treatment or factors more directly related to the country's economic problems?

In psychiatry we have a tendency to associate suicide with mental illness. Since we believe we can treat mental illness we have promoted the myth that we can prevent suicide, but with unintended negative consequences. For example, wrongful death represents one of the top claims in psychiatric malpractice suits. Because of this, those of us in a position to do so shun risky patients, making it more difficult and costly for them to find care, and possibly increasing the risk they will kill themselves. If we get stuck with caring for a risky patient the focus shifts from optimizing treatment (assuming there really is an illness to treat) to desperate attempts to control the patient's behavior.

We should accept that suicide arises almost always out of free choice and focus our efforts on treating illness instead of pretending that we can control behavior. Even when patients who suffer from mental illness choose to end their lives the motivation may have little or nothing to do with the illness.