outer rims...

 

Boss had declared the we would be joining the “outer rim scheme” of the national health insurance bureau plan next year few days ago.

The NHI bureau had started on a claim-pay basis initially. The hospitals submit their bill and the bureau pay as submitted. The bureau has no man power to go through all the cases so it would choose 1 chart per 1000 or per 100 and review the chart. Inappropriate item would be crossed out. The amount of such item would be x 100 (or x1000) and deducted from the payable claim to hospital; that means the chart represent x100 or x1000 of the case note.

The bureau has however allowed the hospital to write appeal for the deduction.

So proper charting is essential, every drug prescribed/exam ordered should be accompanied by appropriate charting.

Under such scheme, some of the hospital had tried very hard to pile up the claim. The annual growth had been enormously high and the govt. had decided to restrict it growth. The bureau had implemented a budget system. 2 schemes were set up -> he inner rim and the outer rim. The budget is separated into 2 pieces. 70% was limited to the budget limit group(inner rim) and 30% to the unlimited group (outer rim) . In the inner rim group, the hospital claim per quarter is set (with reference to claim done during the same period in the past), and a growth of 3-5% is allowed provided the hospital attained the working target set(eg. Total drug cost/total claim <30%....). Any claim beyond the amount would not be paid and the bureau would not deduct any inappropriate item from the claim.

The outer rim portion means the hospital would follow the old rule – claim – review – deduct.2 months before the next quarter, hospitals would have to decided if they wanted to join which portion. If less then 70% of the hospital(counted on claim amount basis) join the inner rim than there would be only one scheme - > the old rule.

Most of the hospital would opt for the inner rim as it is safer and the burden on charting is less. However when a hospital expanded it beds or equipment, the hospital would opt for the outer rim and tried to out perform it past result and gaining chips for bargain in the future.

in the outer rim the deduction rate starts from 20%. That means no matter how good your charting or setting, one would face a minimum deduction of 20% initially and with luck it could be reduce to 10% after appeal.

Not a burden for me but still more time would be spent on typing case note. But I would tried to modified my program. Each time a drug is prescribed an automated generated case note would be done…..and the only job is to print it out….cross my finger……

settling down as health and medical officer....

 

I got my MO posting letter few weeks after I was posted to casualty department. It was just a state away from Selangor. I was reluctant to leave my house and filed my appealed. I had tried to pull some strings but was unable to get those “big chain” graded one. I had asked around and someone had told me that working at the health side (govt. health clinic) is better – no calls and I could focus on my study. I decided to called up the clerk in charge of the posting of the Jabatan Kesihatan Negeri Perak(Perak Health Department). She told me that there is a vacant in Slim river – 120 km from my house and I thought it was acceptable. We made an agreement, I withdraw the appeal and she would post me to the spot. Few days after the conversation, she had called me up again and asked me if I wanted to be posted to Tanjong malim which was closer to Selangor. I told her I gladly accept the offer…

I got my posting letter 3 weeks later and finally started my job as a health and medical officer….

One of my colleagues during the house officer days was posted to there as well and she brief me about the condition….

Me and my father had driven up north and tried to find a house. A single storey terrace house was around RM300-400 and I was lucky to find a new house with the price of RM400 /months….

I still remembered the first day I reported to duty. ……I presented early to the JKN Perak. I waited for a long time as the new Director was busied as she was new to her job as well. I did not met her but was brief by the deputy director (health). I left the office by 11:30pm. I took a drive to Tapah health office when I got my first bombardment from my new boss. The 1^st thing he asked me was – why did I reported late? He had asked me as if I had wandered around ……I explained that I was discharged later from the JKN Perak…..the briefing was brief and he had told me not to “curi tulang” as he would monitor us from time to time….

I drove back to Tg Malim and seen the Medical officer in charge, the next day, I had started my work……it was an easy life , I spent 2 year 8 months at the clinic….

Uninvited...

It was a quiet night until 2am.. I had been disturbed by call from the wards and the ED. Around 3:30am , there was this family wanted an explaination and I walked out from my call room. The explaination was short and I walked back to the office minutes later. When I opened the door, I had seen a shadow moved inside the toilet. The toilet just at the right end of the room from the room, I could see the toilet door just when I stepped into the office.

The ED office sketch.....

 

I was stunt and waited for a second, before I asked "who is there?" A voice anwser from the toilet and "I came for a pee". "PEE" my ass I grumble. A voice means he is definitely human and not any being that belong to another word. I walked into toward a toile and slice the pie. I saw a person about 175cm tall wearing a cap and blue jacket. He saw me and told me that he couldnt find any toilet and so he came here. I was a little annoyed, "WTF" I grumble. I chased him away in a unhappy tone. He quickly zipped his pants and I walked him out from the room. I sat down and had a quick thought that he might be a thief - but I was too tired. The next day, I shared the incident with Lem, and Lem told me that he was definitely a thief. I went to our engineer department and told the manager what had happened. We traced the surveillance camera. Yes, he is definitely a thief. He had entered the hospital 20 minutes before he walked into the office. He had wandered around and took the lift to 7 floors. The nurse was sitting in the station but did not ask him what he wants when he walked into the ward. Then he wandered around the registration desk and waited for me to come out and see my patient. Fortunately I did not take too long to do so and I walked back in heavy paces. If I had not make any sound when I walked back I might had caught him red handed searching for something -then a fight and someone may get hurt....well, I was lucky, nothing was lost. I had a couple of hundred laying on the table along with my laptop, mobile phone....... well, I was lucky I don't have to confrant him ... or else someone might get hurt....

We had actually hired a security guard 3 months ago. However he was sitting in the ED instead of sitting where he should be. If he had sitted at the security desk and questioned someone who had entered the hospital but did not seek help in th ED, the thief might had walked out straight. But it is not the time to make a big issue about this neglect of duty - boss might think it is useless to hire them and we would be back to dark age again.

Casualty department 2

Life in the casualty department was easy….. Most of the MO were easy going persons.. There was one of my high school senior working in the department then. SK was also a Taiwan grad. He had passed the examination and unfortunately 1 year earlier – his HO-ship was 3 years instead of One. The rules had changed 1 year later. Anyway, that was not his only bad luck – he was posted to KLGH and he had opted to travel to-fro from Klang. I heard that he was delayed in one of the department thus extending his HO-ship for another few months. He was competent as he had worked a few years roving in various small hospitals.

We helped out each other then.

There were 2 MO on each shift. Another MO was placed as duty MO. He worked from 8am-5pm. He would cover for all the post mortem case during the day time. The cases were triaged we would see the red then the yellow then the green. I dislike the system in fact. There was once a pakcik(uncle) who came for dizziness. A finger sugar was done and showed high. He was given a yellow tag and he was seen 3+ hrs later after registration.

I tried to see cases as fast as possible. But sometimes the staff couldn’t coup with it.

The medical assistants(MA) played an important role in the casualty department as half of the MO could not intubate properly. SK and I were the MA favorite as we could place any tube without them. I was not that happy actually as 2 things were bothering me then – my posting and part I(MRCP) examination.

I got my posting 2 months later and I was posted to Perak. I wanted Selangor badly as I thought living in my own house could save some expenses and household errand. I appealed but denied….

Casualty department - 1

I remembered the 1^st day I reported myself as Medical officer. My posting was not decided yet and I reported my duty to the office. I asked the admin clerk that I wanted to go to the casualty department. Casualty department was an infamous unit in Hospital Tengku Ampuan Rahimah(HTAR) then. As a house office, we used to get in-appropriate admission – eg. orthopedic case admitted to medical ward…MO which no department wants ( or they have not interested in any department would be posted to casualty department). There were some training MO who called the Casualty department - Junk department.

The casualty department was short of MO then. The admin clerk typed me a letter immediately and asked me to report to Dr Mary – the medical officer in charge immediately. There were no specialist acting as head of department then. An U43 medical officer was posted as in charge instead. Dr Mary was happy when she heard that I had 2 years of working experience in ED setting and asked me if I could start working on that day. I told her why not… I was brought to ED and I started my day shift and went off by 2pm. I was like fish back to water then.

Unlike the ED which had three 8 hrs shift. The ED shift was 7am-2pm(7hrs), 2pm- 9pm(7hrs) and 9pm-7am(10 hrs). No call claim but you would get a day off for a night shift. No lunch/dinner break as well. Each of us worked 18 shifts per month… but going off by 2pm was luxurious for someone working.

Orthopedic - 2

It had been a long time I wrote about my days with the MOH…

The life of the A&E ward HO was easy compare to the forever busy surgical HO. The surgical cases in the A&E were more problematic than the orthopedic cases. I started my tagging in the A&E ward and later the orthopedic wards. I learnt to refreshening (aka amputate) fingers during the period. Well, handy skill for me later during my practice. As I had familiar myself with the system, my life was much easier. Most of the medical officers were Master students. Mr Ong left the department 2 weeks after I joined. He gone into private practice. The 2 specialist was Mr Muthu and Mr Yusof. Mr Muthu was someone loaded. When he got promoted he was posted to IPOH GH and he drove every day (or every odd day) from KL to IPOH(I heard he could make it in 2.5 hrs instead of 4… with a BENZ of coz…) He got his transferred back to Klang after 2 years… Mr Yusof is a Ilizarov man… he did a lot of Ilizarov…

Ilizarov apparatus...

the other 2 were clinical specialists – Mr Wong and Mr Ewe. Mr Wong was master graduate doing his 6 months probation and he is a Sarawakian. He planned to go back to serve the land with his wife(anesthesia master graduate) later. Mr Ewe was FRCS holder doing his 2 years under supervision training in orthopedic. Most of them were nice guys and easy going persons. I had a relaxing time working with them.

There was 1 part which I hate…preparing the OT list … I had to go around the ward and asked around those planned for surgery – weather they pay up for the implant or not…

There were kampung (village) folks that couldn’t afford a plate of RM200…

I learnt the final skill that I wanted badly– closed manual reduction….

At the time I left my orthopedic posting – my MO posting was not decided yet. I did not opt for my surgery and paediatric posting, instead I go to the administration and asked for posting in the Casualty department…I had heard that the life was much easier and I wanted to prepare my part 1 in such an department….

Orthopedic - 1

Before I left the O&G department, I had gone to the clerk in charge of the HO posting. I wanted to do orthopedic as I lack experience in such field. I was told the medical was very short and orthopedic was packed at the time. I told the clerk I preferred orthopedic and I found that when you asked properly and politely you would get what you want...so I joined the orthopedic department after I finished my medical. The orthopedic department was headed by a chinese, Mr Ong. There were lots of Mr instead of Dr in the department. Well, unlike the US system, the UK surgeon was known as Mr or Ms instead of Dr. Back in the old days, surgeon was not regarded as doctor - some of them were barber actually. So they did not carry the title of Dr. But later the title of Mr had become symbol of surgical specialist. Mr Ong was a pakar perunding kanan(Senior consultant) but he was retiring - I had worked under him for 2 wks.

Life in the orthopedic department was much more easy then the Surgical department. The HO calls for surgical deparmtent were decided by the amount of HO in the ward. If 3 HOs was posted in one ward - the HO do a call every 3 days. If 2 HOs then the call would be every odd day. If only 1 HO left - that means the HO do call every day( that means he/she stayed in the ward and cannot go home - and would be called anytime when something need to be attended to).
The HO in ortho do call every 3 days. 2 type of calls was noted - the A&E ward and the ortho ward. The ortho ward HO covered the OT, but unless it was a life threatening condition ( gangrenous limbs which needed urgent amputation) - no ops would be done in the night becoz the Head of Anesthesia department said his medical officer might make mistake when "Giving Gas" in the night.....
The A&E ward was actually the surgical ED. There ED was called the Accident and Emergency department (A&E department) in HTAR. The A&E department saw the medical case and minor trauma. For major trauma, the case would be admitted to the A&E ward straight and managed by relevant surgical or orthopedic MO/HO. There was a call room in the A&E ward: 2 beds : 1 for surgical HO and the other for the ortho HO.
The call was less hazard in the ortho - I was happy then and started my preparation for the MRCP part 1....

A better tomorrow...

I finally told the administration I wanted a reduced in my night shift....

After the asthma attack, I had found that night night had become a stress for me...I went off at noon and hit my bed/sofa/ tilam  by 1:30 or 2pm. In the past, I would wake up by 4 or latest 5pm and feeling better. Now, waking at 5pm means feeling bad - dizziness, nausea and heavy steps.

I had been having mild asthmatic attack from time to time - but recent 1wks , I had a big one again. Although I could suppressed with symbicort and prn ventolin inhaler but the feeling is bad.

I finally walked into the deputy superintendent office and told him that I wanted to cut my shift from 8 to 6...that means I would have 2 weeks with only 1 shift. Life could be much better hopefully. But out of my expectation - the deputy superintedent was not surprised - he had been expecting my request ! Well, he told me that he would work the plan with Lem ( he had been director of emergency department for 1+ yrs now) and Big boss - most probably, Boss and Lem would share 1 shift each... Well, I am glad , at least I would have a better resting time and more daytime work so that I could spend more time in ICU...

Pay might not be less as I could take up more day shift. I should get almost the same pay eventhough the nigth shifts are cut

My progress note program is currently running well. The Order entering part is under developed and currently at the final steps of adjusting user interface.... I am considering of taking some exam such as MSITP... but my aim is in the Nov. - the Medical Informatic Adminstrator exam organized by Taiwan Association of Medical Informatic, I had a 15 marks advantage over the other examinee - there is a part : medical terminology which score 15 out of the 100.

Well, a change in my life and I hope it would be better...

Ving had gone to a fortune teller lately and according to him - I am at the peak of my carrier : I am happy to hear such phrase but I am worried as after the peak/plateau there would be down slope and hopefully not a long long way down....

is life so hard....

It was this post call morning... I was covering for the ICU and ED. There was this 911 call and the ambulance sent in this patient who was shortness of breath. I was wandering around the counter and saw this ambulance arrived. I went out with the ED nurse and the EMT brought someone down from the ambulance. An almost naked male. The adult around 30+ years of age, was wearing a shorts only - uncommon outfit for winter. Eventhough the southern winter is much more warmer than the north but in the morning it would be roughly 20 degree C. I asked the EMT for the history while helping to move the patient into the ED. The EMT told me he was found beside his car. He had parked his car "nicely" along the roadside and lay on the ground just beside his car. The EMT also showed me an inhaler. The patient was wheezing loudly - you can hear his wheezed without using stethescope. With the inhaler found at the scene, the patient is most probably having an severe asthma attack. He is confused though. The SpO2 was 99% and he was not cyanosed. He had passed stool on his shorts - very uncommon findings for an asthma patient who is still breathing. I ordered a neb and asked for an IV line with parenteral solumedrol. I wanted to give him a trial before I intubate him. I asked the EMT again about the shirts or pants he was wearing and the EMT told me they did not notice any around. I went back to the patient and he was drowsy and some yellowish liquid was noted around his oral angle. While I was auscultating, one of the nurse told me she smelled something like agricultural chemical. I had a bad nose especially in the winter. I took a good sniff and noticed there was this smell which is unusual. I pinched the patient hard and asked him if he had drunk any chemicals - the patient nodded. I didn't bother to ask the name and brand of the chemical, he was too dyspneic and drowsy to answer me....I then took him to the active resuscitation area and intubated him under sedation. His pupil had later started to shrink and pin point pupil was noted. I then contacted the local police station and asked them to have a look in the car. A suicidal note was recovered later but no bottle was found. I called up his mother and told them. He had lived 150+km away and worked around our area. We informed his mother and confirmed he is asthma status but his mother denied any factor leading to his suicidal act. The rest of the story was simple - ICU care, extubated the day after, and transferred to his hometown...
After he was alert and recovered from SOB, his physician had asked him about the chenical he use. He wrote down a name but we was unable to find the brand name. There was lots of such chemical in the market; the local manufacture had self packed such chemical and no registration was done. This patient was lucky, atropine was given based on his symptom..
The suicidal rate had been climbing since the past 2 years - lots of peoples facing finacial constratin and opted for suicide. Some even take their children along...a tragedy in such an advance society....

Disaster exercise....Prelude

There was this worst earth quake in 1999 Nov 21st. Casualties and loss of properties beyond imagination..The govt had started to set up their disaster response system based on the US version. But thank god, it was never initiated. The most recent natural disaster was also an earthquake which hit the southern part of taiwan( approx. 70km from my house.) happened on 2006-12-26. I was doing my passing over in ED then.....Some building collapsed, and some life lost...

10 months later, the local govt had decided to do a drill for this earth quake scenario...I become part of it...my colleague was supposed to attend it but as he was sitting for his EM board exam, I took over his place instead. However the exercise was postponed twice and it will be officially done tomorrow. For the past 2 days, I had been to this airport which located at the southern part of Taiwan. It is actually not suitable to deo it in a small airport - but this airport is hardly use - 2 flight per week and sometimes flight postponed due to strong wind. Any small object in the run way might cause a disaster...Anyway, it was done there...

I went to the exercise with 2 nurses+ambulance+1driver. I was the in charge of the yellow area(mod-light injury). The exercise was organized by the county health department. But the army, the national DMAT(south) and regional DMAT were also involved. ...

It was a disaster for me though, the exercise was 70 km from my house, 50 km from my hospital. I will go to the hospital and joined the team and travel to the airport by hospital ambulance.

The schedule for me is terrible....:
Mon night on call
Tue AM - pre exercise 1    PM - pre-exercise 2
Wed AM- pre-exercise 3   PM - pre-exercise 4   night on call again
Thr   AM- pre-exercise 5   PM- official exercise (I will be 34 hrs at work when the exercise over...)

I hope tonight will be smooth...

tired

Calls were bad lately - even when the ED was cool, I was bothered by the ward from time to time.. my last call was worse, I came to work in the evening instead of noon - boss when to Canada to settle his daughter's college matter and I took over his ED shift. It was still a 24 hrs job but I started at 6pm. It lots of different from 12-12 shift, you just can't simply sleep first to prepare youself for call starting from 6pm. So I was darn tired after this 24 hrs shift. I slept by 10pm yesterday when I reached home.
I still felt tired today and I can't rest properly tomorrow after my shift - my LCD TV would be installed by noon tomorrow and when I reached home - I would need to re-arranged the TV table and those cable from TiVo, DVD player, X-box......

Actually it is a tiring month - my work is disturbed by this earth quake disaster exercise - 2 weeks from now. Disaster medicine was one of my interest and when my deputy pengarah asked me about attend it, I gladly complied. I hope to learn some from this exercise. Next year, I will be sitting for the disaster medicine specialist exam - it is not an official specialty recognized by the local govt- but I considered it as a personal interest..