Jul 05 2013
by Guest Blogger: Dr. Michael Rosenblatt
As if you don’t have enough to deal with: Recently in Ohio, the charge of “conspiracy” was added to Government armamentaria to “control” what they regard as “unnecessary tests and procedures.” http://portsmouth-dailytimes.com/bookmark/23001534 In this case, CT scans and treatments for “non-existent” osteo-arthritis were at issue. You may not think of yourself as an audit target. But if you do a larger number of specific codes (more than others in your local specialty), auditors can use computerized forensics to separate you out. For them, it’s as easy as your generating a monthly bank balance on your PC. Then, they will want to see if you documented them. If you didn’t, it’s fraud.
Every healthcare provider should understand the need to prove necessity of tests and procedures. This rests entirely upon the data in your records. There is an excellent place for at least two more (convenient) methods to do this:
- Photo documentation
- “Point” hierarchy check-off worksheets to demonstrate medical/surgical necessity (Cancer gets 10 points, uncontrolled diabetes 10 points, and acute MI 15 points, prior ineffective conservative care 12 points. The negative-point side might be represented by prior good results from non-invasive conservative care, lack of hearing loss from a chronic ear infection. You get it…)
This short article will describe new smart phones and their ability to record important features, some of which are not obvious. Information is “embedded” in the JPG (Digital data that contains a photograph). We can talk more about “point value” documentation at another time.
Over the years, quite a bit has been written about photo-documentation of before and after pictures of surgical and other procedures. Virtually every plastic surgeon uses this technology to the hilt, often with expensive equipment and lighting. But recent improvements in (smart) cell phones has made it possible to more easily expand this technique for doctors who don’t wish to carry around a large, intrusive, heavy digital camera. Virtually every doctor always has their smart phone available, even in a side pocket of their scrubs. Their pictures are surprisingly clear, even at very close range. It helps to try to keep your hands still, because cell phones don’t have “steady-picture” technology.
There are several features that make this very useful, besides being ubiquitous and accessible:
“Name, Location, Date and Captioning”
Smart phone JPGs have the ability to embed all of those (above) features into the photograph. There are applications (apps) that allow you to write your own caption into the photo at the time it is taken. An example is the 99 cent “Photo Date, Location, Caption Stamp Camera” software, made by FunVid Apps, LLC. It is extremely easy to use, has many features and works with iPhone and Apple products. If you have a different brand smart phone, you can easily find a similar app for it. If you ever need to document the time/date/location of a procedure/result, this will prove it for you.
At the Bedside
During rounds, a surgeon may wish to document and “stage” a wound, infection, or ulceration for a variety of reasons. It is impractical and “intrusive” to carry around a digital camera, which although it produces better pictures than a cell phone, can make some patients “uncomfortable.” For some reason, even though it is accomplishing much the same thing, a smart phone does not seem to have the same impact.
Serial images that bear a date, location and time can be immeasurably helpful in establishing the effectiveness of your treatment and its necessity. These images may be extremely helpful in court. It establishes is that you are INTERESTED in the time and effects of your medical choices. This comes across loudly and clearly to a potential future jury. The “court” we are talking about may also include a criminal proceeding against you.
Plaintiff’s Attorneys Detest Photo-Documentation
Any feature that extends more thorough medical records is a threat to plaintiffs’ attorneys, even if it shows a complication or untoward result. It is viewed (correctly) as an extension of the science of medicine/surgery into constant evaluation and documentation. Plaintiffs’ attorneys have a hard time saying that “you didn’t care” or that you “ignored” a downhill progression.
Proof to Government Inspectors
Some specialists who turn in billings to Government venues can be under threat of Government audit. These situations are very dangerous because they pit the power of the entire US Government against miniscule YOU.
Your medical/surgical records become the proof that you billed appropriately. The value of cell phone documentation is that they document the location, time and date of the treatment. Often authorities use cell phones to cement crime convictions, based upon time and location of use. The physician on the other hand is using these very same features to prove the time, location and date of the treatment.
Most physicians ask their patients to sign in at the desk to verify that they were treated on a particular date. You can add photo documentation consent to that form if you wish, or make it part of your intake form(s) for new and returning patients.
Forensic Examination of Photos
One of the features of cell phones is their use of “EXIF” (Exchangeable Image File Format data.) EXIF data is information embedded in the image or video that can contain all or some of the information below (what is actually in the image depends on the camera manufacturer). Typical metadata include:
- Make of the camera that took the picture/video
- Model of the camera
- Serial number of the camera
- Date / time the image was taken (according to the camera’s clock)
- Flash settings
- Aperture settings
- Image resolution
- And more…
Cell phone clocks (and dates) are usually set by the phone network. An argument can be made that this metadata can be tampered with. But the location of the photo is often traceable to a specific geo-code (GPS co-ordinates) on the cell phone. When you take the photo, your GPS location is right in the metadata of the picture. The best way to prove that your photos are genuine and temporally correct is to email them to yourself roughly at time of execution. Whereas messaging may cost money for each picture, email is free. (There are some HIPAA regulations regarding emailing photographs and PHI. You can find out about that here: http://hipaaemailcompliance.org/hipaa-email-compliance/ or here: http://hipaa.yale.edu/guidance/emailconfidentiality.html) It is however, completely legal. [Medical Justice note: HIPAA regulations regarding emailing protected health information (such as pictures that become part of the medical record) require careful thought and planning. Most email applications are not HIPAA compliant. But, if the files / photos are encrypted, it’s certainly easier to take advantage of this medium. Also, the smart-phone itself would need to be password protected and encrypted.]
Some people obsessed with privacy don’t want to leave digital tracks. But you do. Mixing digital tracks (like downloading your data to your PC) is another way to deliberately leave bread-crumbs. Any time data crosses tracks with another device, it leaves a trail. This is to your advantage. For those interested in family photo-enhancement, it is possible to expand the optics of smart phones amazingly with software applications. But you don’t want to be charged with deliberately enhancing a digital evidence photo, because it is possible to do. Software enhancement however always leaves “digital tracks.”
The more effective data you have, the more plaintiffs’ attorneys detest your MP case. Government employees are different. Their investigators are like rabbits. They always seek the easiest path. As you add more and varied documentation; you make easy conviction impossible. No problem. They will just move on to another colleague who doesn’t do this.
(Note: Michael M. Rosenblatt, DPM is not an attorney. He owned and accredited his Medicare Certified Surgical Center North of Seattle. This brief article is not described as legal advice. If you have any legal questions you should immediately hire a licensed attorney. The purpose of this discussion is informational only, much like a magazine article.)
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