Administration Time and Margin

With the demand of the conversion to an EMR, the staff is expressing concern that they do not have enough administration time to properly document the patient’s experience. They feel that perhaps the service to our patients is declining because the amount of time they have to spend on the phone with them has also declined. They feel that the high standard of service that we have had for many years is starting to be affected by the lack of time, that they need to work with this program and also spend the time with the patients both in person and on the phone.

This is a concept that was written about by Dr. Swenson in a book he wrote about 10 years ago called “Margin.” In it he describes ‘margin’ as the time in our lives when we have nothing to do. It is during this time that we spend on relationships with other people, with ourselves, and with God. Life used to afford a lot of margin time in our day to day activities. People will get go to work at 9 o’clock and get done at 5, come home spend time with their family or at home or in the evening reading a book or just writing letters to friends and family. But society has speeded up the demands of the work and all the things that should be done. This starts to eat away at the ‘margin’ little by little until the point where person has no ‘margin’ at all. This creates an incredible stress and tension on the body and the mind. Dr. Swenson is a family doctor, who saw this in his patients as they come in with all of these ailments that are stress driven.

I see this same scenario playing out in my practice right now. As the ‘margin time’ (administration time to spend with patient care) has disappeared, because of the demands of the EMR system, the time my staff has to work with the relationships with the patient has created a tension that is difficult to describe. In this context, it takes away the joy of practicing medicine for my staff and for myself. Yes, I say for my staff. My staff practices medicine as well, as they interact with the patient, listening to their concerns and offering solutions and options for treatment based on the treatment plan. This time spent with the patient has been diminished because of the demands of EMR.

The question is what are we going to do about it! There are a couple of options we are to currently exploring and this would be the subject of a future blog. Basically, in a nutshell, the options include adding more staff or decreasing the time with the patient, which should decrease the profit of the practice. That is my burden.

Ronald S. Prehn, D.D.S.
Diplomate of the American Board of Orofacial Pain
Diplomate of the American Board of Dental Sleep Medicine

Government Influence on Patient Records

I need to pause in my series of blogs about our conversion to Electronic Medical Records (EMR) and comment on a certain aspect of this EMR. There is an aspect of this program called “meaningful use.” When this feature is turned on, it reports to the federal government certain aspects of the patient’s complaints that the government wants to know. These are always (at this time) concerned with lifestyle choices. These include does the patient smoke, what medications they take, do they do drugs, are they married, what race and ethnicity they are, and how many doctors they have seen so on and so forth. At this time the program is used by over 10,000 physicians in the country and is a fast going well-used program, so the government is getting a lot of data from this ‘meaningful use’ aspect of this program. At this point, it is optional to have this turned on and they give financial incentives (reduced maintenance fees) in order to allow this to be used.

I have told the EMR sales person from the start, that I am extremely opposed to having this even in our program and that I do not feel it is government’s place to have this information about its citizens without their consent. I understand the reason for it and that it is designed to develop a national health care system that will meet the needs of the people; however, I feel it is an intrusion into our privacy for the government to track these things. I know in the future they will add certain things into the program that is reported to the government without us even knowing!

The concern I have is what will happen in the future. It is explained to me by the sales person that in 2 to 3 years it will not be an option to turn this feature on, rather it will be required by the government of all EMR systems to report to the government statistics from the patients. Does that concern you? That concerns me. I know that I will fight tooth nail not to have that feature ever in my record and I believe most Dentists, at least that I know, will feel the same way. This leads to a whole host of commentary, blogs, and thoughts. The intrusion of the government into our lives is coming at every possible angle, and this is a concern to this citizen who believes that the fabric of this country is based on the independence and freedom of its people, but I will save my thoughts for another day.

Ronald S. Prehn, D.D.S.
Diplomate of the American Board of Orofacial Pain
Diplomate of the American Board of Dental Sleep Medicine

Going Paperless Part 2

In part 1, I talked about the benefits of paper charts and what they represent. They represent the heart of the patient’s experience in our office and a permanent record of the care we have given them. With the shredding of these charts and our movement into electronic systems, that feeling of permanence and well established written record is not the same at this point. I know it is a new experience for us and my opinion may change about this. I have been working with these electronic charts now for about a week and it is a struggle to properly document and make permanent all the aspects of the patient’s medical condition and my thoughts about where we need to go of the treatment. That is one of the most difficult aspects of this whole experience. The care for our patients and this includes my staff, is always paramount in our mind. We talk to the patient and respond to what they say. The whole purpose of the charts, as we have discovered, is to make a record of our interactions with these patient so that we can refer to them later. It is also a record of the patient as it will be published to the whole world. The new patient exam is entered into the computer in the form of SOAP notes, which stands for subjective symptoms, objective symptoms, assessment, and plan. This initial exam is organized and typed into the computer and printed out in a format, which all the referring doctors, insurance companies, and the patients and any body else in the future, would see as what we determine as their concern and the treatment plan from this point forward. In order to make this an efficient process with the EMR, of course, one has to anticipate what the patient is going to say and put them into drop down boxes so that the assistant can choose the correct responses and then will automatically go into this document. That has taken a month to formulate and I believe it will take me several more months to eventually get it to the point where this system will be efficient.

Ronald S. Prehn, D.D.S.
Diplomate of the American Board of Orofacial Pain
Diplomate of the American Board of Dental Sleep Medicine

Going Paperless, Part 1

It is inevitable in an evolution of a modern medical practice that paper charts become obsolete. Even in our practice, we have been a mix of computer and paper charts for the last 20 years or more. With each year, more upgrades in the programs the paper charts become less and less relevant. However, with that being said, our practice has been in the last 10 years on a plateau as far as progression goes. Our practice management software has always been very sophisticated and its ability to track different aspects of patient care has been very good; however, I have always had a chart in my hand when talking about the patient with my staff. My staff has always carried the charts around and the charts have always been the hub of the practice. Think about it for a minute. The chart is where you go when you ask a question about the patient, their history, what they said when they first came in and is all available with the flip of a page. The chart is also the route through the day as I go from room to room. The chart sits outsides the patients’ door signaling to me that that is where I am to go. While the financial aspect of the patient’s experience in our office has been on a computer for most of my career, it is the medical care of the patient that has always been in the chart.

I believe that this is the most heart-wrenching aspect of abandoning the paper chart system. It almost seems as if one is giving up caring for these patients. The other aspect of charts, is that charts are permanent. What is written on paper is a permanent record of their experience in our office and a permanent record of their lives as they intersect with our care. It is all documented in their paper charts. With the electronic charts, things do not seem as permanent and things do not seem the same.

Ronald S. Prehn, D.D.S.
Diplomate of the American Board of Orofacial Pain
Diplomate of the American Board of Dental Sleep Medicine

The Character of Our Staff

We have recently undergone a tumultuous change in our practice. We have thrown out the paper charts and gone in to Electronic Medical Records (EMR). I have written several blogs on the heart-wrenching experience this has been and will continue to be for the next few months. But the purpose of this today is to tell the world what incredible staff we have at this office. The week long training has just ended and it has been a week that has been full of frustration and aches. Each staff member has been thrown into trying to learn this system, which has not at any turn been friendly to the way we do things in this office. Every person has worked extremely hard to try to modify the program to point out weaknesses, to point out where it does not fit the patient’s needs, to point out where it does not meet the needs of the practice in this mission, and so forth. Today was the day that we saw a half-day of 4 patients and I have to tell you that it was extremely nerve wracking as we approached this day. Last night, I did not sleep hardly at all. When I got to work this morning and we had a usual morning huddle it turns out not a single staff member slept well at last night either! Everybody was nervous about the patient’s who were to come in and nervous that they would not be taking care of at high level of care that we give in our practice, because everybody was concerned that the EMR was going to distract us from that. I for one, was shocked at that revelation. This demonstrates the commitment in the passion our staff has, to the person, for the care of the patient. They focus on the patient and deal with the computer as it is. They have all maintained at that focus and that mission. I am extremely proud to be associated with co-workers such as this. I cannot put into words what that means. That means that I am working with people who are as committed to the patient as I am. Those of you who are reading this who are team leaders in a business or team leaders in a medical practice know exactly what I am saying here. It is extremely rare to have an entire staff to be this committed to the patient care. Usually it is 1 or 2 people in the staff who are committed to the care of our patient’s as a priority over the business of the practice and I am proud to say that my entire staff is of that rarity.

I can rest assured that I if ever get replaced in this practice by another doctor that my staff will carry on with a mission of caring for our patients in pain who come to our doors. It is God who brings the patients to our door for us to intersect with and it is God who is the head of this practice. He is the one who brings the patients to us and it is a validation to me that God has also brought the staff that we have to our office by the way they have responded to this incredibly tumultuous event of throwing out the paper charts and going EMR.

As a Dentist who depends entirely on his staff for delivery of quality care, I have to say that I am blessed to have the coworkers that I have and I hope they also feel blessed with the passion they
have as I know that rewards come when they see the patient’s respond to the treatment that we provide for them.

Ronald S. Prehn, D.D.S.
Diplomate of the American Board of Orofacial Pain
Diplomate of the American Board of Dental Sleep Medicine

THE GRID OF UNDERSTANDING

In my career in the profession of Orofacial Pain and Dental Sleep Medicine, I have always been drawn to the excitement of learning new concepts and new approaches to understanding and applying this understanding to treating patients with these conditions. I would go to conferences and seminars and come back with a head full of information. Then I work hard and try to make it applicable and integrate these new concepts into my practice. In other words, I have always approached learning with a spirit of an open mind to what information is provided. I would put this information through scientific process as far as validating its worthiness. However, I always kept an open mind to what people had to say and to consider it as either true, partially true, or false. This has put me into the position of providing the best care possible for my patients.

In the last few years, I have had the opportunity to take this understanding to a new level with research that I have been doing with the patients in my practice. It is difficult to do this because of the fact that I have to run the business of medicine at the same time. In doing this, I have collaborated with various other medical specialists and have come to understand a new thinking of the role of sleep disorder breathing in Orofacial Pain.

As I share this new understanding with my fellow colleagues in Orofacial Pain and Sleep Medicine, I have several observations to make. As I share my new understanding with fellow Dentists in the role of teaching, these concepts have been very well received by my colleagues. It just makes common sense when you consider it with the evidence that is out there. Even though this is so new that the research is very sketchy at this time, it just makes sense. I am involved in research studies to validate these new concepts, which I hope will verify the understanding that I have come to integrate into my thinking of orofacial pain and TMD. I am talking about the relationsihp between bruxing and the collapse of the airway at night.

However, when it comes to sharing my understanding with my peers who also treat exclusively orofacial pain or dental sleep medicine, my teaching is met with much skepticism. At first, I was shocked by this perception, however, I have also come to realize what the problem is. The problem is what I call the “a grid of understanding.” This comes after years of learning and using this knowledge to treat patients. When you come to understand a concept and you integrate it into your grid of understanding, it becomes further validation of what you already know to be true. As new information comes on board and is presented, it has to fit that grid of understanding or it will probably be rejected. The longer you stay on that grid that the more difficult it is to bring new information and concepts into the world from which you operate. This becomes a challenge when new concepts are presented especially as “radical” as the concepts that I might be presenting. I also have a grid of understanding, however, I tried to keep my grid open to new ideas and new concepts, while very carefully putting them through filters of scientific reasoning and validation.

I do not fault my colleagues in orofacial pain at all. What I am trying to put forth is of course very new and I know full well that these ideas may pan out to be only partially true. That is the way I do present these theories, however, it is very interesting the different ways it has been received by my colleagues.

I personally do not mind being challenged because it causes me to defend my ideas and when I have to defend them, I have to question them myself. I enjoy this type of interaction with my peers, so I embrace their skepticism and challenges. My only thought in regards to this is that I sometimes wish they would receive ideas with more open mind or at least consider these new ideas as they go back and work it through their filter or their grid of understanding. Then they can come back to me with their cause of their concerns or possibly further validation of new ideas.

Ronald S. Prehn, D.D.S.
Diplomate of the American Board of Orofacial Pain
Diplomate of the American Board of Dental Sleep Medicine

GENE EXPRESSION IS YOUR DESTINY PART 2

In the previous blog, I had shared what I have learned about some new research concerning gene expression. The human gene is the same in everybody but is expressed differently as it is modified by various factors such as smoking, alcohol, drugs, and other lifestyle modifiers. I also explained how this effect can be inherited to the next generation and in reality, the research has shown that this has actually passed down to 4 generations. Think of it. If you smoke for a number of years or you do drugs through teen ager years, this can permanently modify the expression of your genes that will affect the rest of your life. It is not known exactly how much it will affect you 50 years in the future. However, little things will start to be different in you than the other people with the same gene. This would be factor in such things as pain syndromes, headaches, fibromyalgia, fatigue, sleep disorders, and cardiovascular problems. This is quite shocking news for the human race! God has designed us to be incredibly adaptive to degenerative processes and to toxicity, but you can see as the generations go on, this could get worse for everybody.

The tragic aspect of this is that 99.9% of the human population would never know this. The hope would be that as research continues and this can be validated, that the medical profession will pick up on this research and start looking at patient care in a whole new light. Unfortunately, it will have to be driven by economics in our society today. It would have to be economically profitable for people to live a healthier lifestyle in order for the medical profession to actually use this information to help people in their overall health. This would mean that nutrition counseling and lifestyle counseling would be part of the normal patient care. At this present time, insurance wants nothing to do with this believing it as a waste of time. But as this research continues and starts to verify and validate these facts, then perhaps insurance companies will actually pay the physicians to do these things.

In the meantime, keep watch for this information as it gets out and my advice will be for my patients for now on to live a better lifestyle and what they eat and what wises they chose.

Ronald S. Prehn, D.D.S.
Diplomate of the American Board of Orofacial Pain
Diplomate of the American Board of Dental Sleep Medicine

GENE EXPRESSION IS YOUR DESTINY PART 1

All humans have the same genes, which is the basic makeup of who we are or what the human is; but what makes us different is a concept called ‘gene expression’. It is how our gene is expressed that determines our individuality. I am at the American Academy of Orofacial Pain national meeting and I just heard a lecture on gene expression. This introduces some new concepts, which are very thought provoking and significant. This speaks to the age-old controversy of nature versus nurture. Nature is our gene, which determines that we are human. However, nature does effect the expression of the gene. Nurture would be all the things that actually had been documented to affect the expression of our gene such as our diet, lifestyle, drugs, alcohol, and other lifestyle modifiers. All these things have been documented now to affect the expression of our genes.

The concept is known as ‘epigenetics’. The word ‘epi’ is a Greek word that means ‘around’. For example, epicenter is around the center. Epigene is an expression of the gene that is around the actual gene. Gene expression can come out as how our body deals with heart disease or other risk factors that affect our heart or all the things that cause pain and our perception of pain. For example, have you ever wondered why some people have chronic pain or aches or pain all the time and some people do not? This might be because of the way the genes have been expressed. Why do some people have heart attacks at age 60 who never smoked or drank and yet some people who have heart attacks when they are 90 years old and they had smoked all their life? It has to do with the epigenetics.

Now for the startling new revolution. The speaker has documented the fact that gene expression or modified gene expression can actually be hereditary! That means that if a pregnant mother has alcohol or decides to smoke, that it will modify her gene expression. But on top of that, it will modify her baby’s gene expression and her baby’s child’s gene expression! So toxicity from drugs and alcohol and smoking can be passed down through 4 generations. This has now been documented in research.

Not only is this a frightening possibility, but it also helps us to explain some of the things that I have pondered in previous blogs of which the proliferation of autoimmune diseases in my generation. I have spoken about the autoimmune diseases that I am seeing now in patients that I never did even 20 years ago. These diseases include the lupus, arthritis in young people, Sjogren disease, and the list goes on and on. There will be more blogs on this subject in the future.

There is a lot of think about here.

Ronald S. Prehn, D.D.S.
Diplomate of the American Board of Orofacial Pain
Diplomate of the American Board of Dental Sleep Medicine

FUTURE OF PAIN CONTROL

I have just returned from a facial pain update and have some thoughts as to the future of pain control. As I mentioned in one of my other blogs, there has been no new pain medication in the last 7 years. They have all been rearrangements of current medications and different dispersal systems. What I have learned at this update is that as our understanding of the source of pain becomes more clear, the ability to reduce the pain will also become more specific.

As we understand not just what nerve fibers and neurotransmitters are involved in regulation of pain, but the deeper more specific aspects of pain control is understood at the level of the gene. We are becoming more knowledgeable as to how the body controls its own pain as different genes express themselves at different times with different types of insults. The more we understand how pain is produced at the sub molecular level, the more we understand how we can possibly stop the pain.

Let me try to illustrate what I am talking about. Lets say you live in a community on a beach. One day a ship comes to the area of your beach and every morning at 3:00 a.m., it lets out a screeching noise that goes on for an hour. The ship is too far to shoot at with guns, is too far to throw rocks at it, is too far to scream at it, therefore the only choice we have is to somehow insulate yourself from the noise by putting earphones on or buying a house that is sound proof. That is sort of a way painkillers are today. We do not stop the pain, all we try to do is to mask it or try to reduce the way it feels to us. But wonder if we could build a certain type of boat that will go across the water and in that boat, we could put a bomb or possibly a secret agent to be able to get over to the ship and the ship would greet it as another ship and then the bomb could be let off at the appropriate time or the agent can dismantle the screaming siren. That would be a very specific way to eliminate the pain as we find the “boat” or what they call, “the carrier” to take specific medications to eliminate the pain. That is where the future is. They are also using this in cancer research and in treatment of cancer. The more specific our medications can be, the less side effects there will be and the more comfortable and more effective will be the pain control.

Sincerely Yours,

Ronald S. Prehn, D.D.S.
Diplomate of the American Board of Orofacial Pain
Diplomate of the American Board of Dental Sleep Medicine

WHERE ARE THE PAINKILLERS?

I was at a facial pain update this weekend and we had a lecture from a professor about facial pain. He made the comment that in the last seven years, there have only been 2 new painkillers introduced into the market place. One is for intense cancer pain and the other is for specifically pancreatic pain. Therefore, in the general analgesic or painkilling category, there have been ZERO new painkillers introduced in the last 7 years!!!.

I feel I need to preface this with the well-known fact that pain management doctors know, and that is that painkillers are very nonspecific. In other words, while they reduce pain levels, they also have significant side effects, as these drugs affect other systems of the body as well. There is a huge need for more specific painkillers, especially in regards to somatic pain, which is muscles and joints and the pain that most people experience. Anybody who has been prescribed any sort of painkillers, know all the side effects these medications have and healthcare providers also have to deal with these side effects on a daily basis.

This caused me to stop and think what is the real issue here. Why are there not more pain medications being brought into the healthcare system? Is the cost of research and development too high? Is the regulation by the government too much? Is the fact that the cost is so high that these costs cannot be recovered before the drugs go generic?

I hope that this problem resolves itself soon. Some other new research that is being done on pain management is promising. The newer medications that hopefully will be coming soon will be extremely specific for the pain. They will be carried to the side of the pain by different modalities and different unique ways. In fact, some of the expression of pain is going to be dealt with on the gene level. I am not sure how many more years it takes before this type of pain control is available to the patients; however, it seems so unique and exciting that I hope that the cost of developing these new types of pain management drugs will be profitable to the pharmaceutical companies, so that they will become available to the patients.

Ronald S. Prehn, D.D.S.
Diplomate of the American Board of Orofacial Pain
Diplomate of the American Board of Dental Sleep Medicine