I’m convinced that observation status is rapidly becoming a meaningful factor in patients’ decision to file a malpractice lawsuit.

First, let me concede that I don’t know of any hard data to support my claim. I even asked the nation’s largest malpractice insurer about this, and they didn’t have any data on it. I think that is because observation status has only become a really big issue in the last couple of years, and since it typically takes several years for a malpractice suit to conclude, it just hasn’t found its way onto their radar yet.

But I’m pretty sure that will change within the next few years.

Implications

As any seasoned practitioner in our field knows, all outpatient and inpatient physician charges for Medicare patients, along with those of other licensed practitioners, are billed through Medicare Part B. After meeting a deductible, patients with traditional fee-for-service Medicare are generally responsible for 20% of all approved Part B charges, with no upper limit. For patients seen by a large number of providers while hospitalized, this 20% can really add up. Some patients have a secondary insurance that pays for this.

Hospital charges for patients on inpatient status are billed through Medicare Part A. Patients have an annual Part A deductible, and only in the case of very long inpatient stays will they have to pay more than that for inpatient care each year.

But hospital charges for patients on observation status are billed through Part B. And because hospital charges add up so quickly, the 20% of this that the patient is responsible for can be a lot of money—thousands of dollars, even for stays of less than 24 hours. Understandably, patients are not at all happy about this.

Let’s say you’re admitted overnight on observation status and your doctor orders your usual Advair inhaler. You use it once. Most hospitals aren’t able to ensure compliance with regulations around dispensing medications for home use like a pharmacy, so they won’t let you take the inhaler home. A few weeks later you’re stunned to learn that the hospital charged $10,000 for all services provided, and you’re responsible for 20% of the allowable amount PLUS the cost of all “self administered” drugs, like inhalers, eye drops, and calcitonin nasal spray. You look over your bill to see that you’re asked to pay $350 for the inhaler you used once and couldn’t even take home with you! Many self-administered medications, including eye drops and calcitonin nasal spray, result in similarly alarming charges to patients.

On top of the unpleasant surprise of a large hospital bill, Medicare won’t pay for skilled nursing facility (SNF) care for patients who are on observation status. That is, observation is not a “qualifying” stay for beneficiaries to access their SNF benefit.

It is easy to see why patients are unhappy about observation status.

The Media Message

News media are making the public aware of the potentially high financial costs they face if placed on observation status. But, too often, they oversimplify the issue, making it seem as though the choice of observation vs. inpatient status is entirely up to the treating doctor.

Saying that this decision is entirely up to the doctor is a lot like saying it is entirely up to you to determine how fast you drive on a freeway. In a sense that is correct, because no one else is in your car to control how fast you go and, in theory, you could choose to go 100 mph or 30 mph. The only problem is that it wouldn’t be long before you’d be in trouble with the law. So you don’t have complete autonomy to choose your speed; you have to comply with the laws. The same is true for doctors choosing observation status. We must comply with regulations in choosing the status or face legal consequences like fines or accusations of fraud.

 

Most news stories, like this one from NBC news (www.nbcnews.com/video/nightly-news/54511352#54511352) in February, are generally accurate but leave out the important fact that hospitals and doctors have little autonomy to choose the status the patient prefers. Instead, media often simply encourage patients on observation status to argue for a change to inpatient status and “be persistent.” More and more often, patients and families are arguing with the treating doctor; in many cases, that is a hospitalist.

Complaints Surge

At the 2014 SHM annual meeting last spring in Las Vegas, I spoke with many hospitalists who said that, increasingly, they are targets of observation-status complaints. One hospitalist group recently had each doctor list his or her top three frustrations with work; difficult and stressful conversations about observation status topped the list.

Patient anger regarding observation status can turn a satisfied patient into an angry one. We all know that unhappy patients are the ones most likely to pursue malpractice lawsuits. While anger over observation status doesn’t equal medical malpractice, it can change a patient’s opinion of our care, which may in some cases result in a malpractice claim.

Solutions

Medicare is unlikely to do away with observation status, so the best way to prevent complaints is to ensure that all its implications are explained to patients and families, ideally before they’re put into the hospital (e.g., while still in the ED). I think it is best if this message is delivered by someone other than the treating doctor(s): For example, a case manager might handle the discussion. Of course, patients and families are often too overwhelmed in the ED to absorb this information, so the message may need to be repeated later.

Maybe everyone should tell observation patients, “We’re going to observe you” without using any form of the word “admission.” And having these patients stay in distinct observation units probably reduces misunderstandings and complaints compared to the common practice of mixing these patients in “regular” hospital floors housing those on inpatient status.

Unfortunately, I couldn’t find research data to support this idea.

I bet some hospitals have even more elegant and effective ways to reduce misunderstandings and complaints around observation status. I’d love to hear from you if you know of any. E-mail me at [email protected].

---

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

I’m convinced that observation status is rapidly becoming a meaningful factor in patients’ decision to file a malpractice lawsuit.

First, let me concede that I don’t know of any hard data to support my claim. I even asked the nation’s largest malpractice insurer about this, and they didn’t have any data on it. I think that is because observation status has only become a really big issue in the last couple of years, and since it typically takes several years for a malpractice suit to conclude, it just hasn’t found its way onto their radar yet.

But I’m pretty sure that will change within the next few years.

Implications

As any seasoned practitioner in our field knows, all outpatient and inpatient physician charges for Medicare patients, along with those of other licensed practitioners, are billed through Medicare Part B. After meeting a deductible, patients with traditional fee-for-service Medicare are generally responsible for 20% of all approved Part B charges, with no upper limit. For patients seen by a large number of providers while hospitalized, this 20% can really add up. Some patients have a secondary insurance that pays for this.

Hospital charges for patients on inpatient status are billed through Medicare Part A. Patients have an annual Part A deductible, and only in the case of very long inpatient stays will they have to pay more than that for inpatient care each year.

But hospital charges for patients on observation status are billed through Part B. And because hospital charges add up so quickly, the 20% of this that the patient is responsible for can be a lot of money—thousands of dollars, even for stays of less than 24 hours. Understandably, patients are not at all happy about this.

Let’s say you’re admitted overnight on observation status and your doctor orders your usual Advair inhaler. You use it once. Most hospitals aren’t able to ensure compliance with regulations around dispensing medications for home use like a pharmacy, so they won’t let you take the inhaler home. A few weeks later you’re stunned to learn that the hospital charged $10,000 for all services provided, and you’re responsible for 20% of the allowable amount PLUS the cost of all “self administered” drugs, like inhalers, eye drops, and calcitonin nasal spray. You look over your bill to see that you’re asked to pay $350 for the inhaler you used once and couldn’t even take home with you! Many self-administered medications, including eye drops and calcitonin nasal spray, result in similarly alarming charges to patients.

On top of the unpleasant surprise of a large hospital bill, Medicare won’t pay for skilled nursing facility (SNF) care for patients who are on observation status. That is, observation is not a “qualifying” stay for beneficiaries to access their SNF benefit.

It is easy to see why patients are unhappy about observation status.

The Media Message

News media are making the public aware of the potentially high financial costs they face if placed on observation status. But, too often, they oversimplify the issue, making it seem as though the choice of observation vs. inpatient status is entirely up to the treating doctor.

Saying that this decision is entirely up to the doctor is a lot like saying it is entirely up to you to determine how fast you drive on a freeway. In a sense that is correct, because no one else is in your car to control how fast you go and, in theory, you could choose to go 100 mph or 30 mph. The only problem is that it wouldn’t be long before you’d be in trouble with the law. So you don’t have complete autonomy to choose your speed; you have to comply with the laws. The same is true for doctors choosing observation status. We must comply with regulations in choosing the status or face legal consequences like fines or accusations of fraud.

 

Most news stories, like this one from NBC news (www.nbcnews.com/video/nightly-news/54511352#54511352) in February, are generally accurate but leave out the important fact that hospitals and doctors have little autonomy to choose the status the patient prefers. Instead, media often simply encourage patients on observation status to argue for a change to inpatient status and “be persistent.” More and more often, patients and families are arguing with the treating doctor; in many cases, that is a hospitalist.

Complaints Surge

At the 2014 SHM annual meeting last spring in Las Vegas, I spoke with many hospitalists who said that, increasingly, they are targets of observation-status complaints. One hospitalist group recently had each doctor list his or her top three frustrations with work; difficult and stressful conversations about observation status topped the list.

Patient anger regarding observation status can turn a satisfied patient into an angry one. We all know that unhappy patients are the ones most likely to pursue malpractice lawsuits. While anger over observation status doesn’t equal medical malpractice, it can change a patient’s opinion of our care, which may in some cases result in a malpractice claim.

Solutions

Medicare is unlikely to do away with observation status, so the best way to prevent complaints is to ensure that all its implications are explained to patients and families, ideally before they’re put into the hospital (e.g., while still in the ED). I think it is best if this message is delivered by someone other than the treating doctor(s): For example, a case manager might handle the discussion. Of course, patients and families are often too overwhelmed in the ED to absorb this information, so the message may need to be repeated later.

Maybe everyone should tell observation patients, “We’re going to observe you” without using any form of the word “admission.” And having these patients stay in distinct observation units probably reduces misunderstandings and complaints compared to the common practice of mixing these patients in “regular” hospital floors housing those on inpatient status.

Unfortunately, I couldn’t find research data to support this idea.

I bet some hospitals have even more elegant and effective ways to reduce misunderstandings and complaints around observation status. I’d love to hear from you if you know of any. E-mail me at [email protected].

---

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

I’m convinced that observation status is rapidly becoming a meaningful factor in patients’ decision to file a malpractice lawsuit.

First, let me concede that I don’t know of any hard data to support my claim. I even asked the nation’s largest malpractice insurer about this, and they didn’t have any data on it. I think that is because observation status has only become a really big issue in the last couple of years, and since it typically takes several years for a malpractice suit to conclude, it just hasn’t found its way onto their radar yet.

But I’m pretty sure that will change within the next few years.

Implications

As any seasoned practitioner in our field knows, all outpatient and inpatient physician charges for Medicare patients, along with those of other licensed practitioners, are billed through Medicare Part B. After meeting a deductible, patients with traditional fee-for-service Medicare are generally responsible for 20% of all approved Part B charges, with no upper limit. For patients seen by a large number of providers while hospitalized, this 20% can really add up. Some patients have a secondary insurance that pays for this.

Hospital charges for patients on inpatient status are billed through Medicare Part A. Patients have an annual Part A deductible, and only in the case of very long inpatient stays will they have to pay more than that for inpatient care each year.

But hospital charges for patients on observation status are billed through Part B. And because hospital charges add up so quickly, the 20% of this that the patient is responsible for can be a lot of money—thousands of dollars, even for stays of less than 24 hours. Understandably, patients are not at all happy about this.

Let’s say you’re admitted overnight on observation status and your doctor orders your usual Advair inhaler. You use it once. Most hospitals aren’t able to ensure compliance with regulations around dispensing medications for home use like a pharmacy, so they won’t let you take the inhaler home. A few weeks later you’re stunned to learn that the hospital charged $10,000 for all services provided, and you’re responsible for 20% of the allowable amount PLUS the cost of all “self administered” drugs, like inhalers, eye drops, and calcitonin nasal spray. You look over your bill to see that you’re asked to pay $350 for the inhaler you used once and couldn’t even take home with you! Many self-administered medications, including eye drops and calcitonin nasal spray, result in similarly alarming charges to patients.

On top of the unpleasant surprise of a large hospital bill, Medicare won’t pay for skilled nursing facility (SNF) care for patients who are on observation status. That is, observation is not a “qualifying” stay for beneficiaries to access their SNF benefit.

It is easy to see why patients are unhappy about observation status.

The Media Message

News media are making the public aware of the potentially high financial costs they face if placed on observation status. But, too often, they oversimplify the issue, making it seem as though the choice of observation vs. inpatient status is entirely up to the treating doctor.

Saying that this decision is entirely up to the doctor is a lot like saying it is entirely up to you to determine how fast you drive on a freeway. In a sense that is correct, because no one else is in your car to control how fast you go and, in theory, you could choose to go 100 mph or 30 mph. The only problem is that it wouldn’t be long before you’d be in trouble with the law. So you don’t have complete autonomy to choose your speed; you have to comply with the laws. The same is true for doctors choosing observation status. We must comply with regulations in choosing the status or face legal consequences like fines or accusations of fraud.

 

Most news stories, like this one from NBC news (www.nbcnews.com/video/nightly-news/54511352#54511352) in February, are generally accurate but leave out the important fact that hospitals and doctors have little autonomy to choose the status the patient prefers. Instead, media often simply encourage patients on observation status to argue for a change to inpatient status and “be persistent.” More and more often, patients and families are arguing with the treating doctor; in many cases, that is a hospitalist.

Complaints Surge

At the 2014 SHM annual meeting last spring in Las Vegas, I spoke with many hospitalists who said that, increasingly, they are targets of observation-status complaints. One hospitalist group recently had each doctor list his or her top three frustrations with work; difficult and stressful conversations about observation status topped the list.

Patient anger regarding observation status can turn a satisfied patient into an angry one. We all know that unhappy patients are the ones most likely to pursue malpractice lawsuits. While anger over observation status doesn’t equal medical malpractice, it can change a patient’s opinion of our care, which may in some cases result in a malpractice claim.

Solutions

Medicare is unlikely to do away with observation status, so the best way to prevent complaints is to ensure that all its implications are explained to patients and families, ideally before they’re put into the hospital (e.g., while still in the ED). I think it is best if this message is delivered by someone other than the treating doctor(s): For example, a case manager might handle the discussion. Of course, patients and families are often too overwhelmed in the ED to absorb this information, so the message may need to be repeated later.

Maybe everyone should tell observation patients, “We’re going to observe you” without using any form of the word “admission.” And having these patients stay in distinct observation units probably reduces misunderstandings and complaints compared to the common practice of mixing these patients in “regular” hospital floors housing those on inpatient status.

Unfortunately, I couldn’t find research data to support this idea.

I bet some hospitals have even more elegant and effective ways to reduce misunderstandings and complaints around observation status. I’d love to hear from you if you know of any. E-mail me at [email protected].

---

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

EDITOR’S NOTE: Second in an occasional series of reviews of the Hospital Medicine: Current Concepts series by members of Team Hospitalist.

Summary

The third installment in the Hospital Medicine: Current Concepts series, Becoming a Consummate Clinician is written in two parts. Part 1, “Medical Musts and Must-Nots,” is focused on the basics of being a clinician: gathering an appropriate history, performing an effective physical examination, and formulating differential diagnoses. This section in particular is geared toward house officers and attending physicians on teaching teams. While the audience here is primarily clinicians on a teaching service, there is good advice for those in any practice setting about avoiding common mistakes and developing clinical sagacity.

In this first section, we are given advisement on treatment of and with medications. Regardless of a clinician’s level of experience, it is worth reading this text to review and internalize these authors’ advice regarding medication pitfalls. Simply putting this advice into one’s daily practice of medicine will take any practitioner a long way toward becoming a “consummate clinician.”

Part 2, “Medical Masteries,” logically builds upon material presented in Part 1. The final section of the book addresses aspects of critical analysis of medical data and encourages engagement of critical thinking skills in all aspects of clinical decision-making. Specific topics addressed include reducing medical errors, reevaluating evidence-based medicine, deconstructing several widely cited medical aphorisms, identifying sources of cognitive errors, and transforming information into understanding.

The authors devoted the final chapter to the discussion of “What is disease?” and “What is health?” which, quite frankly, adds little value to the book.

Drs. Goldberger and Goldberger discuss what they term the “interstitial curriculum”—what is not explicitly taught but should be. Included in the “interstitial curriculum” is examination of cognitive errors and how we are more apt to make these in the era of “high-throughput” patient care. Another topic included in their “interstitial curriculum” is the paucity of attention paid to addressing uncertainty in all aspects of medicine. These topics are worth the cost of this book, even if it only helps promote awareness of these important ideas and bring the discussion to a larger audience.

Analysis

There are times in this book, particularly in the beginning, when the reader feels this text was written for the benefit of the house officer and those practitioners serving on inpatient teaching services. Continued reading, however, finds brilliant advice for clinicians in all practice settings and in all stages of their careers.

The encouragement of all readers to rethink everything we assume to be true and to seek a deeper understanding of what we “know” is priceless.

The quotes included throughout the book were both valuable and enjoyable. The authors included quotes from Plutarch to Hector Barbosa from Pirates of the Caribbean. One quote that is particularly germane to the practice of hospital medicine in this age of the Hospital Consumer Assessment of Healthcare Providers and Systems comes from Sir William Osler:

 

“Remember…that every patient upon whom you wait will examine you critically and form an estimate of you by the way in which you conduct yourself at the bedside. Skill and nicety in manipulation, in the simple act of feeling the pulse or in the performance of any minor operation, will do more towards establishing confidence in you than a string of diplomas, or the reputation of extensive hospital experience.”

Conversely, the computer-generated graphics added no value and were, in fact, a detractor. Hopefully, the next edition will not feature the sophomorically rendered bridge advising us to “bridge the classroom-to-clinic gap,” the flamingo, or the zigzagging line, among others.

---

Dr. Lindsey is chief operations officer and strategist of Synergy Surgicalists, and a member of Team Hospitalist.

EDITOR’S NOTE: Second in an occasional series of reviews of the Hospital Medicine: Current Concepts series by members of Team Hospitalist.

Summary

The third installment in the Hospital Medicine: Current Concepts series, Becoming a Consummate Clinician is written in two parts. Part 1, “Medical Musts and Must-Nots,” is focused on the basics of being a clinician: gathering an appropriate history, performing an effective physical examination, and formulating differential diagnoses. This section in particular is geared toward house officers and attending physicians on teaching teams. While the audience here is primarily clinicians on a teaching service, there is good advice for those in any practice setting about avoiding common mistakes and developing clinical sagacity.

In this first section, we are given advisement on treatment of and with medications. Regardless of a clinician’s level of experience, it is worth reading this text to review and internalize these authors’ advice regarding medication pitfalls. Simply putting this advice into one’s daily practice of medicine will take any practitioner a long way toward becoming a “consummate clinician.”

Part 2, “Medical Masteries,” logically builds upon material presented in Part 1. The final section of the book addresses aspects of critical analysis of medical data and encourages engagement of critical thinking skills in all aspects of clinical decision-making. Specific topics addressed include reducing medical errors, reevaluating evidence-based medicine, deconstructing several widely cited medical aphorisms, identifying sources of cognitive errors, and transforming information into understanding.

The authors devoted the final chapter to the discussion of “What is disease?” and “What is health?” which, quite frankly, adds little value to the book.

Drs. Goldberger and Goldberger discuss what they term the “interstitial curriculum”—what is not explicitly taught but should be. Included in the “interstitial curriculum” is examination of cognitive errors and how we are more apt to make these in the era of “high-throughput” patient care. Another topic included in their “interstitial curriculum” is the paucity of attention paid to addressing uncertainty in all aspects of medicine. These topics are worth the cost of this book, even if it only helps promote awareness of these important ideas and bring the discussion to a larger audience.

Analysis

There are times in this book, particularly in the beginning, when the reader feels this text was written for the benefit of the house officer and those practitioners serving on inpatient teaching services. Continued reading, however, finds brilliant advice for clinicians in all practice settings and in all stages of their careers.

The encouragement of all readers to rethink everything we assume to be true and to seek a deeper understanding of what we “know” is priceless.

The quotes included throughout the book were both valuable and enjoyable. The authors included quotes from Plutarch to Hector Barbosa from Pirates of the Caribbean. One quote that is particularly germane to the practice of hospital medicine in this age of the Hospital Consumer Assessment of Healthcare Providers and Systems comes from Sir William Osler:

 

“Remember…that every patient upon whom you wait will examine you critically and form an estimate of you by the way in which you conduct yourself at the bedside. Skill and nicety in manipulation, in the simple act of feeling the pulse or in the performance of any minor operation, will do more towards establishing confidence in you than a string of diplomas, or the reputation of extensive hospital experience.”

Conversely, the computer-generated graphics added no value and were, in fact, a detractor. Hopefully, the next edition will not feature the sophomorically rendered bridge advising us to “bridge the classroom-to-clinic gap,” the flamingo, or the zigzagging line, among others.

---

Dr. Lindsey is chief operations officer and strategist of Synergy Surgicalists, and a member of Team Hospitalist.

EDITOR’S NOTE: Second in an occasional series of reviews of the Hospital Medicine: Current Concepts series by members of Team Hospitalist.

Summary

The third installment in the Hospital Medicine: Current Concepts series, Becoming a Consummate Clinician is written in two parts. Part 1, “Medical Musts and Must-Nots,” is focused on the basics of being a clinician: gathering an appropriate history, performing an effective physical examination, and formulating differential diagnoses. This section in particular is geared toward house officers and attending physicians on teaching teams. While the audience here is primarily clinicians on a teaching service, there is good advice for those in any practice setting about avoiding common mistakes and developing clinical sagacity.

In this first section, we are given advisement on treatment of and with medications. Regardless of a clinician’s level of experience, it is worth reading this text to review and internalize these authors’ advice regarding medication pitfalls. Simply putting this advice into one’s daily practice of medicine will take any practitioner a long way toward becoming a “consummate clinician.”

Part 2, “Medical Masteries,” logically builds upon material presented in Part 1. The final section of the book addresses aspects of critical analysis of medical data and encourages engagement of critical thinking skills in all aspects of clinical decision-making. Specific topics addressed include reducing medical errors, reevaluating evidence-based medicine, deconstructing several widely cited medical aphorisms, identifying sources of cognitive errors, and transforming information into understanding.

The authors devoted the final chapter to the discussion of “What is disease?” and “What is health?” which, quite frankly, adds little value to the book.

Drs. Goldberger and Goldberger discuss what they term the “interstitial curriculum”—what is not explicitly taught but should be. Included in the “interstitial curriculum” is examination of cognitive errors and how we are more apt to make these in the era of “high-throughput” patient care. Another topic included in their “interstitial curriculum” is the paucity of attention paid to addressing uncertainty in all aspects of medicine. These topics are worth the cost of this book, even if it only helps promote awareness of these important ideas and bring the discussion to a larger audience.

Analysis

There are times in this book, particularly in the beginning, when the reader feels this text was written for the benefit of the house officer and those practitioners serving on inpatient teaching services. Continued reading, however, finds brilliant advice for clinicians in all practice settings and in all stages of their careers.

The encouragement of all readers to rethink everything we assume to be true and to seek a deeper understanding of what we “know” is priceless.

The quotes included throughout the book were both valuable and enjoyable. The authors included quotes from Plutarch to Hector Barbosa from Pirates of the Caribbean. One quote that is particularly germane to the practice of hospital medicine in this age of the Hospital Consumer Assessment of Healthcare Providers and Systems comes from Sir William Osler:

 

“Remember…that every patient upon whom you wait will examine you critically and form an estimate of you by the way in which you conduct yourself at the bedside. Skill and nicety in manipulation, in the simple act of feeling the pulse or in the performance of any minor operation, will do more towards establishing confidence in you than a string of diplomas, or the reputation of extensive hospital experience.”

Conversely, the computer-generated graphics added no value and were, in fact, a detractor. Hopefully, the next edition will not feature the sophomorically rendered bridge advising us to “bridge the classroom-to-clinic gap,” the flamingo, or the zigzagging line, among others.

---

Dr. Lindsey is chief operations officer and strategist of Synergy Surgicalists, and a member of Team Hospitalist.

If you are a physician considering employment with a hospital or private practice in which hospital medical staff privileges will be needed or you are currently employed by a hospital or private practice and have medical staff privileges, it is imperative that you understand your rights as an employee and as a member of the hospital’s medical staff, along with the interplay between those two roles.

Employment Agreement and Hospital Medical Staff Bylaws

As an employee of a hospital or private practice, you will have an employment agreement that governs the terms of your employment. In addition, if you are on the hospital’s medical staff, you will also be subject to the hospital’s medical staff bylaws, which govern the terms of your staff membership and clinical privileges.

At the onset of an employment relationship, many physicians focus on the terms of their employment agreements, often ignoring the terms of the medical staff bylaws. This could lead to unexpected surprises, usually toward the end of the employment relationship, because both documents need to be read in conjunction with each other.

Beware of conflicting terms in your employment agreement on the one hand and the medical staff bylaws on the other. Although an employment agreement may include seemingly beneficial terms, hidden language often has the effect of negating its terms by qualifying the employment agreement with language contained in the bylaws. Examples include:

—“In the event of a conflict between the terms of the Physician’s Employment Agreement and the Medical Staff Bylaws, the Medical Staff Bylaws shall control.”

—“Subject to the Medical Staff Bylaws, Physician may …”

—“Except as otherwise stated in the Medical Staff Bylaws, Physician may …”

—“Except as permitted by the Medical Staff Bylaws, Physician may not …”

Termination of Medical Staff Privileges: Impact on Employment Agreement

Whether you are employed by a hospital or a private practice, your employment is likely at risk if your hospital medical staff privileges are suspended, revoked, or restricted. Even if your medical staff privileges are later reinstated, the initial suspension may trigger termination of your employment agreement.

Therefore, it is important to understand your due process rights, outlined in the hospital’s medical staff bylaws, as to how your privileges can be suspended, revoked, or restricted, as well as the procedure the hospital must undergo to make such a decision.

Medical staff bylaws also include a procedure for due process, including fair hearings and appeal mechanisms for medical staff decisions, such as privilege suspension, revocation, and restrictions.

Termination of Employment: Impact on Medical Staff Privileges

For hospital employees and most hospital-based physicians, termination of your employment agreement, whether for cause or without cause, may be automatic grounds for termination of your staff privileges. In such a case, your due process rights under the medical staff bylaws as they relate to your staff privileges are waived, and you will not be afforded the fair hearing and appeal procedure typically available to office-based physicians on the hospital’s medical staff.

Also, your employment agreement may contractually require you to resign from the hospital’s medical staff upon termination of the employment relationship. For example:

“Physician covenants and agrees that upon termination of Physician’s employment with Employer (whether for cause or without cause), Physician will resign from the medical staff of Hospital X, thereby relinquishing any right to due process pursuant to the medical staff bylaws.”

Some employment agreements may go even further and prohibit you from re-applying for medical staff privileges at that hospital for a stated period of time. For example:

 

“Physician further agrees that Physician shall not re-apply for medical staff privileges at Hospital X within two (2) years following the later of the termination of Physician’s employment or the effective date of termination of such medical staff privileges at Hospital X.”

Don’t forget about the hospital’s medical staff bylaws when entertaining an employment relationship with a hospital or private practice. The hospital’s medical staff bylaws should be reviewed in conjunction with the employment agreement.

---

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

If you are a physician considering employment with a hospital or private practice in which hospital medical staff privileges will be needed or you are currently employed by a hospital or private practice and have medical staff privileges, it is imperative that you understand your rights as an employee and as a member of the hospital’s medical staff, along with the interplay between those two roles.

Employment Agreement and Hospital Medical Staff Bylaws

As an employee of a hospital or private practice, you will have an employment agreement that governs the terms of your employment. In addition, if you are on the hospital’s medical staff, you will also be subject to the hospital’s medical staff bylaws, which govern the terms of your staff membership and clinical privileges.

At the onset of an employment relationship, many physicians focus on the terms of their employment agreements, often ignoring the terms of the medical staff bylaws. This could lead to unexpected surprises, usually toward the end of the employment relationship, because both documents need to be read in conjunction with each other.

Beware of conflicting terms in your employment agreement on the one hand and the medical staff bylaws on the other. Although an employment agreement may include seemingly beneficial terms, hidden language often has the effect of negating its terms by qualifying the employment agreement with language contained in the bylaws. Examples include:

—“In the event of a conflict between the terms of the Physician’s Employment Agreement and the Medical Staff Bylaws, the Medical Staff Bylaws shall control.”

—“Subject to the Medical Staff Bylaws, Physician may …”

—“Except as otherwise stated in the Medical Staff Bylaws, Physician may …”

—“Except as permitted by the Medical Staff Bylaws, Physician may not …”

Termination of Medical Staff Privileges: Impact on Employment Agreement

Whether you are employed by a hospital or a private practice, your employment is likely at risk if your hospital medical staff privileges are suspended, revoked, or restricted. Even if your medical staff privileges are later reinstated, the initial suspension may trigger termination of your employment agreement.

Therefore, it is important to understand your due process rights, outlined in the hospital’s medical staff bylaws, as to how your privileges can be suspended, revoked, or restricted, as well as the procedure the hospital must undergo to make such a decision.

Medical staff bylaws also include a procedure for due process, including fair hearings and appeal mechanisms for medical staff decisions, such as privilege suspension, revocation, and restrictions.

Termination of Employment: Impact on Medical Staff Privileges

For hospital employees and most hospital-based physicians, termination of your employment agreement, whether for cause or without cause, may be automatic grounds for termination of your staff privileges. In such a case, your due process rights under the medical staff bylaws as they relate to your staff privileges are waived, and you will not be afforded the fair hearing and appeal procedure typically available to office-based physicians on the hospital’s medical staff.

Also, your employment agreement may contractually require you to resign from the hospital’s medical staff upon termination of the employment relationship. For example:

“Physician covenants and agrees that upon termination of Physician’s employment with Employer (whether for cause or without cause), Physician will resign from the medical staff of Hospital X, thereby relinquishing any right to due process pursuant to the medical staff bylaws.”

Some employment agreements may go even further and prohibit you from re-applying for medical staff privileges at that hospital for a stated period of time. For example:

 

“Physician further agrees that Physician shall not re-apply for medical staff privileges at Hospital X within two (2) years following the later of the termination of Physician’s employment or the effective date of termination of such medical staff privileges at Hospital X.”

Don’t forget about the hospital’s medical staff bylaws when entertaining an employment relationship with a hospital or private practice. The hospital’s medical staff bylaws should be reviewed in conjunction with the employment agreement.

---

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

If you are a physician considering employment with a hospital or private practice in which hospital medical staff privileges will be needed or you are currently employed by a hospital or private practice and have medical staff privileges, it is imperative that you understand your rights as an employee and as a member of the hospital’s medical staff, along with the interplay between those two roles.

Employment Agreement and Hospital Medical Staff Bylaws

As an employee of a hospital or private practice, you will have an employment agreement that governs the terms of your employment. In addition, if you are on the hospital’s medical staff, you will also be subject to the hospital’s medical staff bylaws, which govern the terms of your staff membership and clinical privileges.

At the onset of an employment relationship, many physicians focus on the terms of their employment agreements, often ignoring the terms of the medical staff bylaws. This could lead to unexpected surprises, usually toward the end of the employment relationship, because both documents need to be read in conjunction with each other.

Beware of conflicting terms in your employment agreement on the one hand and the medical staff bylaws on the other. Although an employment agreement may include seemingly beneficial terms, hidden language often has the effect of negating its terms by qualifying the employment agreement with language contained in the bylaws. Examples include:

—“In the event of a conflict between the terms of the Physician’s Employment Agreement and the Medical Staff Bylaws, the Medical Staff Bylaws shall control.”

—“Subject to the Medical Staff Bylaws, Physician may …”

—“Except as otherwise stated in the Medical Staff Bylaws, Physician may …”

—“Except as permitted by the Medical Staff Bylaws, Physician may not …”

Termination of Medical Staff Privileges: Impact on Employment Agreement

Whether you are employed by a hospital or a private practice, your employment is likely at risk if your hospital medical staff privileges are suspended, revoked, or restricted. Even if your medical staff privileges are later reinstated, the initial suspension may trigger termination of your employment agreement.

Therefore, it is important to understand your due process rights, outlined in the hospital’s medical staff bylaws, as to how your privileges can be suspended, revoked, or restricted, as well as the procedure the hospital must undergo to make such a decision.

Medical staff bylaws also include a procedure for due process, including fair hearings and appeal mechanisms for medical staff decisions, such as privilege suspension, revocation, and restrictions.

Termination of Employment: Impact on Medical Staff Privileges

For hospital employees and most hospital-based physicians, termination of your employment agreement, whether for cause or without cause, may be automatic grounds for termination of your staff privileges. In such a case, your due process rights under the medical staff bylaws as they relate to your staff privileges are waived, and you will not be afforded the fair hearing and appeal procedure typically available to office-based physicians on the hospital’s medical staff.

Also, your employment agreement may contractually require you to resign from the hospital’s medical staff upon termination of the employment relationship. For example:

“Physician covenants and agrees that upon termination of Physician’s employment with Employer (whether for cause or without cause), Physician will resign from the medical staff of Hospital X, thereby relinquishing any right to due process pursuant to the medical staff bylaws.”

Some employment agreements may go even further and prohibit you from re-applying for medical staff privileges at that hospital for a stated period of time. For example:

 

“Physician further agrees that Physician shall not re-apply for medical staff privileges at Hospital X within two (2) years following the later of the termination of Physician’s employment or the effective date of termination of such medical staff privileges at Hospital X.”

Don’t forget about the hospital’s medical staff bylaws when entertaining an employment relationship with a hospital or private practice. The hospital’s medical staff bylaws should be reviewed in conjunction with the employment agreement.

---

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

In May 2012, the Office of Inspector General (OIG) released an executive summary, Coding Trends of Medicare Evaluation and Management (E/M) Services, that examined physician services from 2001 to 2010. More specifically, the OIG analyzed E/M claims to identify physicians (approximately 1700) who consistently billed higher level (i.e., more complex and more expensive) E/M codes in 2010, but they did not determine whether the E/M claims were inappropriate.¹ The OIG recommended that the Centers for Medicare and Medicaid Services (CMS):

• Continue to educate physicians on proper billing for E/M services;
• Encourage its contractors to review physicians’ billing for E/M services; and
• Review physicians who bill higher level E/M codes for appropriate action.¹

When documenting patient history, physicians must be aware of the common discrepancies that occur. Although the physician becomes familiar with the patient as he/she provides care throughout the hospitalization, the auditor must acquaint himself or herself with the patient using only the limited information provided in the progress note.

When documentation is requested by the payer for a specific service date, only the documentation from that service date is considered. Be sure that the information is adequate to support both clinical care and the reported service level.

Patient History Requirements

Chief complaint. The chief complaint (CC) is the reason for the visit as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).

• Incomplete CC example: “Follow-up”;
• Better CC example: “Follow-up for severe abdominal cramping.”

History of present illness. The history of present illness (HPI) describes the development or progression of the patient’s current problem(s). The traditional HPI elements recognized in the 1995 documentation guidelines are location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.^2,3

The physician must obtain and personally document the HPI. He/she also has the option to link to the HPI documented by residents (i.e., residents, fellows, interns) in compliance with the teaching physician rules or nonphysician practitioners (i.e., nurse practitioners and physician assistants) as defined by the split-shared billing rules. An auditor will not accept HPI information if the physician attempts to link to any other individual, even if that person may be qualified to obtain this (e.g. registered nurse, medical assistant) or is a student (e.g. medical students, nurse practitioner students).

Because auditors recognize both 1995 and 1997 documentation guidelines, they must also recognize the HPI differences. The 1997 HPI format promotes the status of the patient’s chronic or inactive conditions.⁴ The physician receives one credit for each chronic condition that is noted, along with documentation of what has occurred since the last physician encounter as it relates to the chronic condition (e.g. “patient has a history of chronic obstructive bronchitis without acute exacerbation in past six months”).

Physicians may utilize either style of HPI documentation, and auditors must review provider records against each set of guidelines. The final audited result reflects the highest visit level supported by either set of guidelines. For example, if physician documentation yields an “extended” HPI when 1995 guidelines are used but only a “brief” HPI (see Table 2) when 1997 guidelines are reviewed, the auditor awards the physician credit for the “extended” HPI.

• 1995 example: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
• 1997 example: “Diabetes controlled by oral medication; hyperlipidemia stable on simvastatin with increased dietary efforts; hypertension stable with pressures ranging from 130-140/80-90 overnight” (status of three chronic conditions).

 

Review of systems. A review of systems (ROS) is a series of questions inquiring about additional signs, symptoms, or problems currently or previously experienced by the patient as related to the CC or presenting problem. The recognized systems are constitutional; eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.^2,3

The physician may choose to document the ROS by making a notation for individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal) and occasional runny nose (ears, nose, mouth, throat).” Alternatively, the physician may inquire about all of the systems but only document the positive and pertinent negative findings related to the CC, along with an additional comment that “all other systems are negative.” Most Medicare audit contractors currently accept this method as long as all systems were reviewed.^5,6,7,8,9

Be advised that ROS information can be documented by anyone, including the patient. The physician must remember to reference ROS information that is completed by individuals other than residents or nonphysician practitioners (the physician is already required to reference the documentation of the latter individuals under the Teaching Physician Rules or Split-Shared Billing Rules).

Past, family, and social histories. Documentation of past, family, and social histories (PFSH) involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. An auditor credits the physician for a single comment correlated to each history for the PFSH. Using the term “noncontributory” (N/C) with any of the histories can result in downcoding. Many contractors do not allow this statement due to previous misunderstandings over its use.

• Incomplete PFSH example: “Patient is status-post cholecystectomy in August 2013; family history N/C; patient is former smoker” (Note: “family history N/C” is not accepted by most contractors).
• Better PFSH example: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s Esophagus; no tobacco or alcohol use.”

PFSH data can also be documented by anyone, including the patient, and the physician must reference the PFSH information in his own progress note. Re-documenting the PFSH is not necessary unless a revision is required. PFSH documentation is only required for initial care services (i.e., initial hospital care, initial observation care, consultations). It is not required for subsequent care services, unless additional pertinent information that impacts care is obtained during the hospital stay.

Common Problems to Avoid

Information cannot be obtained. Some contractors will not penalize the physician for the inability to ascertain complete historical information as long as there is evidenced documentation of an attempt to obtain the information. When the physician cannot extract historical information from the patient directly and no other source is available, the physician documents that he is “unable to obtain” the history. Additionally, the physician must provide a comment to explain why the information is unobtainable (e.g. patient confused, no caregiver present) along with the available information from the limited resources (e.g. emergency medical technicians, records from previous hospitalizations at the same facility).

Previous information referenced. When referencing items from a previous encounter, be sure to include the referenced information when documentation is requested by the payer. Per CMS guidelines, the ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by either describing any new ROS and/or PFSH information or noting that there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.²

 

Pre-op clearance and HPI deficiencies. HPI is typically not as deficient as the ROS or family history elements; however, HPI underdocumentation is mostly associated with encounters for pre-op clearance. The physician may state that “patient requires pre-op clearance for left knee repair.” In the absence of any comorbidities or acute illness, HPI documentation may be missing. The physician should remember to identify the details of the presenting problem: “Patient runs five miles daily. Knee felt unstable after running two weeks ago. Swelling and intermittent sharp pain 7/10. Patient has been taking ibuprofen daily without relief.”

Not medically necessary. Remember not to document any elements for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

Varying levels of history. E/M services are selected based on the content of the three “key” components: history, exam, and decision-making (or visit time). If counseling and/or coordination of care does not encompass >50% of the physician’s total visit time or the service is not exclusively designated as a time-based service (e.g. critical care and discharge day management), the physician’s service time is not considered.

Documentation for each of the three key components must support the reported visit level when reporting initial hospital care and consultations (for those payers who still recognize consultation codes). Subsequent hospital care (e.g. 99233) only requires supportive documentation from two key components. Medical decision-making should be one of the two supporting components in order to demonstrate the medical necessity and nature of the presenting problem; the other supporting component can be history or exam.

Each visit category (e.g. initial hospital care or subsequent hospital care) and service level (e.g. 99221-99233) identifies corresponding documentation requirements. Failure to document any essential element in a given visit level (e.g. family history required for a comprehensive history when billing for 99222 and 99223) may result in service denial or downcoding (e.g. 99221). Be aware of what an auditor expects when reviewing patient history (see Table 1).

There are four levels of history: problem-focused, expanded problem-focused, detailed, and comprehensive. An auditor determines the number of history elements documented in the progress note (see Table 2). The history level corresponds to the lowest documented element. For example, if physician documentation includes four HPI elements, eight ROS, and a comment in each of the PFSHs, the history level is equivalent to “detailed.” The history would support initial hospital care 99221 or subsequent hospital care 99233.

---

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Levinson DR. Department of Health and Human Services, Office of Inspector General: Coding Trends of Medicare Evaluation and Management Services. May 2012. Available at: oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. Accessed October 4, 2014.
2. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed October 4, 2014.
3. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. CPT 2013 Professional Edition (Current Procedural Terminology). Chicago: American Medical Association Press; 2012:4-10.
4. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed October 4, 2014.
5. Noridian Healthcare Solutions. Medicare Part B: Evaluation and Management Workshop Questions and Answers. Available at: www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkZpEVAyylqZyOfqel&tmpl=part_b_viewnews&style=part_ab_viewnews Accessed on October 4, 2014.
6. WPS Medicare Health Insurance. J5 MAC Part B: Documentation (Q&As). Available at: www.wpsmedicare.com/j5macpartb/resources/provider_types/evalmngmntqa.shtml. Accessed October 4, 2014.
7. NHIC, Corp. Building Your Medicare Knowledge: Advanced Building Blocks. Available at: www.medicarenhic.com/providers/pubs/AdvdBuildBlocks061212.pdf.
8. Palmetto GBA. Jurisdiction 11 Part B: History Component. Available at: www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Part%20B~EM%20Help%20Center~General%20Articles~History%20Component?open&Expand=1. Accessed October 4, 2014.
9. Novitas Solutions. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: https://www.novitas-solutions.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed October 4, 2014.

In May 2012, the Office of Inspector General (OIG) released an executive summary, Coding Trends of Medicare Evaluation and Management (E/M) Services, that examined physician services from 2001 to 2010. More specifically, the OIG analyzed E/M claims to identify physicians (approximately 1700) who consistently billed higher level (i.e., more complex and more expensive) E/M codes in 2010, but they did not determine whether the E/M claims were inappropriate.¹ The OIG recommended that the Centers for Medicare and Medicaid Services (CMS):

• Continue to educate physicians on proper billing for E/M services;
• Encourage its contractors to review physicians’ billing for E/M services; and
• Review physicians who bill higher level E/M codes for appropriate action.¹

When documenting patient history, physicians must be aware of the common discrepancies that occur. Although the physician becomes familiar with the patient as he/she provides care throughout the hospitalization, the auditor must acquaint himself or herself with the patient using only the limited information provided in the progress note.

When documentation is requested by the payer for a specific service date, only the documentation from that service date is considered. Be sure that the information is adequate to support both clinical care and the reported service level.

Patient History Requirements

Chief complaint. The chief complaint (CC) is the reason for the visit as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).

• Incomplete CC example: “Follow-up”;
• Better CC example: “Follow-up for severe abdominal cramping.”

History of present illness. The history of present illness (HPI) describes the development or progression of the patient’s current problem(s). The traditional HPI elements recognized in the 1995 documentation guidelines are location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.^2,3

The physician must obtain and personally document the HPI. He/she also has the option to link to the HPI documented by residents (i.e., residents, fellows, interns) in compliance with the teaching physician rules or nonphysician practitioners (i.e., nurse practitioners and physician assistants) as defined by the split-shared billing rules. An auditor will not accept HPI information if the physician attempts to link to any other individual, even if that person may be qualified to obtain this (e.g. registered nurse, medical assistant) or is a student (e.g. medical students, nurse practitioner students).

Because auditors recognize both 1995 and 1997 documentation guidelines, they must also recognize the HPI differences. The 1997 HPI format promotes the status of the patient’s chronic or inactive conditions.⁴ The physician receives one credit for each chronic condition that is noted, along with documentation of what has occurred since the last physician encounter as it relates to the chronic condition (e.g. “patient has a history of chronic obstructive bronchitis without acute exacerbation in past six months”).

Physicians may utilize either style of HPI documentation, and auditors must review provider records against each set of guidelines. The final audited result reflects the highest visit level supported by either set of guidelines. For example, if physician documentation yields an “extended” HPI when 1995 guidelines are used but only a “brief” HPI (see Table 2) when 1997 guidelines are reviewed, the auditor awards the physician credit for the “extended” HPI.

• 1995 example: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
• 1997 example: “Diabetes controlled by oral medication; hyperlipidemia stable on simvastatin with increased dietary efforts; hypertension stable with pressures ranging from 130-140/80-90 overnight” (status of three chronic conditions).

 

Review of systems. A review of systems (ROS) is a series of questions inquiring about additional signs, symptoms, or problems currently or previously experienced by the patient as related to the CC or presenting problem. The recognized systems are constitutional; eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.^2,3

The physician may choose to document the ROS by making a notation for individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal) and occasional runny nose (ears, nose, mouth, throat).” Alternatively, the physician may inquire about all of the systems but only document the positive and pertinent negative findings related to the CC, along with an additional comment that “all other systems are negative.” Most Medicare audit contractors currently accept this method as long as all systems were reviewed.^5,6,7,8,9

Be advised that ROS information can be documented by anyone, including the patient. The physician must remember to reference ROS information that is completed by individuals other than residents or nonphysician practitioners (the physician is already required to reference the documentation of the latter individuals under the Teaching Physician Rules or Split-Shared Billing Rules).

Past, family, and social histories. Documentation of past, family, and social histories (PFSH) involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. An auditor credits the physician for a single comment correlated to each history for the PFSH. Using the term “noncontributory” (N/C) with any of the histories can result in downcoding. Many contractors do not allow this statement due to previous misunderstandings over its use.

• Incomplete PFSH example: “Patient is status-post cholecystectomy in August 2013; family history N/C; patient is former smoker” (Note: “family history N/C” is not accepted by most contractors).
• Better PFSH example: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s Esophagus; no tobacco or alcohol use.”

PFSH data can also be documented by anyone, including the patient, and the physician must reference the PFSH information in his own progress note. Re-documenting the PFSH is not necessary unless a revision is required. PFSH documentation is only required for initial care services (i.e., initial hospital care, initial observation care, consultations). It is not required for subsequent care services, unless additional pertinent information that impacts care is obtained during the hospital stay.

Common Problems to Avoid

Information cannot be obtained. Some contractors will not penalize the physician for the inability to ascertain complete historical information as long as there is evidenced documentation of an attempt to obtain the information. When the physician cannot extract historical information from the patient directly and no other source is available, the physician documents that he is “unable to obtain” the history. Additionally, the physician must provide a comment to explain why the information is unobtainable (e.g. patient confused, no caregiver present) along with the available information from the limited resources (e.g. emergency medical technicians, records from previous hospitalizations at the same facility).

Previous information referenced. When referencing items from a previous encounter, be sure to include the referenced information when documentation is requested by the payer. Per CMS guidelines, the ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by either describing any new ROS and/or PFSH information or noting that there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.²

 

Pre-op clearance and HPI deficiencies. HPI is typically not as deficient as the ROS or family history elements; however, HPI underdocumentation is mostly associated with encounters for pre-op clearance. The physician may state that “patient requires pre-op clearance for left knee repair.” In the absence of any comorbidities or acute illness, HPI documentation may be missing. The physician should remember to identify the details of the presenting problem: “Patient runs five miles daily. Knee felt unstable after running two weeks ago. Swelling and intermittent sharp pain 7/10. Patient has been taking ibuprofen daily without relief.”

Not medically necessary. Remember not to document any elements for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

Varying levels of history. E/M services are selected based on the content of the three “key” components: history, exam, and decision-making (or visit time). If counseling and/or coordination of care does not encompass >50% of the physician’s total visit time or the service is not exclusively designated as a time-based service (e.g. critical care and discharge day management), the physician’s service time is not considered.

Documentation for each of the three key components must support the reported visit level when reporting initial hospital care and consultations (for those payers who still recognize consultation codes). Subsequent hospital care (e.g. 99233) only requires supportive documentation from two key components. Medical decision-making should be one of the two supporting components in order to demonstrate the medical necessity and nature of the presenting problem; the other supporting component can be history or exam.

Each visit category (e.g. initial hospital care or subsequent hospital care) and service level (e.g. 99221-99233) identifies corresponding documentation requirements. Failure to document any essential element in a given visit level (e.g. family history required for a comprehensive history when billing for 99222 and 99223) may result in service denial or downcoding (e.g. 99221). Be aware of what an auditor expects when reviewing patient history (see Table 1).

There are four levels of history: problem-focused, expanded problem-focused, detailed, and comprehensive. An auditor determines the number of history elements documented in the progress note (see Table 2). The history level corresponds to the lowest documented element. For example, if physician documentation includes four HPI elements, eight ROS, and a comment in each of the PFSHs, the history level is equivalent to “detailed.” The history would support initial hospital care 99221 or subsequent hospital care 99233.

---

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Levinson DR. Department of Health and Human Services, Office of Inspector General: Coding Trends of Medicare Evaluation and Management Services. May 2012. Available at: oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. Accessed October 4, 2014.
2. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed October 4, 2014.
3. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. CPT 2013 Professional Edition (Current Procedural Terminology). Chicago: American Medical Association Press; 2012:4-10.
4. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed October 4, 2014.
5. Noridian Healthcare Solutions. Medicare Part B: Evaluation and Management Workshop Questions and Answers. Available at: www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkZpEVAyylqZyOfqel&tmpl=part_b_viewnews&style=part_ab_viewnews Accessed on October 4, 2014.
6. WPS Medicare Health Insurance. J5 MAC Part B: Documentation (Q&As). Available at: www.wpsmedicare.com/j5macpartb/resources/provider_types/evalmngmntqa.shtml. Accessed October 4, 2014.
7. NHIC, Corp. Building Your Medicare Knowledge: Advanced Building Blocks. Available at: www.medicarenhic.com/providers/pubs/AdvdBuildBlocks061212.pdf.
8. Palmetto GBA. Jurisdiction 11 Part B: History Component. Available at: www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Part%20B~EM%20Help%20Center~General%20Articles~History%20Component?open&Expand=1. Accessed October 4, 2014.
9. Novitas Solutions. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: https://www.novitas-solutions.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed October 4, 2014.

In May 2012, the Office of Inspector General (OIG) released an executive summary, Coding Trends of Medicare Evaluation and Management (E/M) Services, that examined physician services from 2001 to 2010. More specifically, the OIG analyzed E/M claims to identify physicians (approximately 1700) who consistently billed higher level (i.e., more complex and more expensive) E/M codes in 2010, but they did not determine whether the E/M claims were inappropriate.¹ The OIG recommended that the Centers for Medicare and Medicaid Services (CMS):

• Continue to educate physicians on proper billing for E/M services;
• Encourage its contractors to review physicians’ billing for E/M services; and
• Review physicians who bill higher level E/M codes for appropriate action.¹

When documenting patient history, physicians must be aware of the common discrepancies that occur. Although the physician becomes familiar with the patient as he/she provides care throughout the hospitalization, the auditor must acquaint himself or herself with the patient using only the limited information provided in the progress note.

When documentation is requested by the payer for a specific service date, only the documentation from that service date is considered. Be sure that the information is adequate to support both clinical care and the reported service level.

Patient History Requirements

Chief complaint. The chief complaint (CC) is the reason for the visit as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).

• Incomplete CC example: “Follow-up”;
• Better CC example: “Follow-up for severe abdominal cramping.”

History of present illness. The history of present illness (HPI) describes the development or progression of the patient’s current problem(s). The traditional HPI elements recognized in the 1995 documentation guidelines are location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.^2,3

The physician must obtain and personally document the HPI. He/she also has the option to link to the HPI documented by residents (i.e., residents, fellows, interns) in compliance with the teaching physician rules or nonphysician practitioners (i.e., nurse practitioners and physician assistants) as defined by the split-shared billing rules. An auditor will not accept HPI information if the physician attempts to link to any other individual, even if that person may be qualified to obtain this (e.g. registered nurse, medical assistant) or is a student (e.g. medical students, nurse practitioner students).

Because auditors recognize both 1995 and 1997 documentation guidelines, they must also recognize the HPI differences. The 1997 HPI format promotes the status of the patient’s chronic or inactive conditions.⁴ The physician receives one credit for each chronic condition that is noted, along with documentation of what has occurred since the last physician encounter as it relates to the chronic condition (e.g. “patient has a history of chronic obstructive bronchitis without acute exacerbation in past six months”).

Physicians may utilize either style of HPI documentation, and auditors must review provider records against each set of guidelines. The final audited result reflects the highest visit level supported by either set of guidelines. For example, if physician documentation yields an “extended” HPI when 1995 guidelines are used but only a “brief” HPI (see Table 2) when 1997 guidelines are reviewed, the auditor awards the physician credit for the “extended” HPI.

• 1995 example: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
• 1997 example: “Diabetes controlled by oral medication; hyperlipidemia stable on simvastatin with increased dietary efforts; hypertension stable with pressures ranging from 130-140/80-90 overnight” (status of three chronic conditions).

 

Review of systems. A review of systems (ROS) is a series of questions inquiring about additional signs, symptoms, or problems currently or previously experienced by the patient as related to the CC or presenting problem. The recognized systems are constitutional; eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.^2,3

The physician may choose to document the ROS by making a notation for individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal) and occasional runny nose (ears, nose, mouth, throat).” Alternatively, the physician may inquire about all of the systems but only document the positive and pertinent negative findings related to the CC, along with an additional comment that “all other systems are negative.” Most Medicare audit contractors currently accept this method as long as all systems were reviewed.^5,6,7,8,9

Be advised that ROS information can be documented by anyone, including the patient. The physician must remember to reference ROS information that is completed by individuals other than residents or nonphysician practitioners (the physician is already required to reference the documentation of the latter individuals under the Teaching Physician Rules or Split-Shared Billing Rules).

Past, family, and social histories. Documentation of past, family, and social histories (PFSH) involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. An auditor credits the physician for a single comment correlated to each history for the PFSH. Using the term “noncontributory” (N/C) with any of the histories can result in downcoding. Many contractors do not allow this statement due to previous misunderstandings over its use.

• Incomplete PFSH example: “Patient is status-post cholecystectomy in August 2013; family history N/C; patient is former smoker” (Note: “family history N/C” is not accepted by most contractors).
• Better PFSH example: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s Esophagus; no tobacco or alcohol use.”

PFSH data can also be documented by anyone, including the patient, and the physician must reference the PFSH information in his own progress note. Re-documenting the PFSH is not necessary unless a revision is required. PFSH documentation is only required for initial care services (i.e., initial hospital care, initial observation care, consultations). It is not required for subsequent care services, unless additional pertinent information that impacts care is obtained during the hospital stay.

Common Problems to Avoid

Information cannot be obtained. Some contractors will not penalize the physician for the inability to ascertain complete historical information as long as there is evidenced documentation of an attempt to obtain the information. When the physician cannot extract historical information from the patient directly and no other source is available, the physician documents that he is “unable to obtain” the history. Additionally, the physician must provide a comment to explain why the information is unobtainable (e.g. patient confused, no caregiver present) along with the available information from the limited resources (e.g. emergency medical technicians, records from previous hospitalizations at the same facility).

Previous information referenced. When referencing items from a previous encounter, be sure to include the referenced information when documentation is requested by the payer. Per CMS guidelines, the ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by either describing any new ROS and/or PFSH information or noting that there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.²

 

Pre-op clearance and HPI deficiencies. HPI is typically not as deficient as the ROS or family history elements; however, HPI underdocumentation is mostly associated with encounters for pre-op clearance. The physician may state that “patient requires pre-op clearance for left knee repair.” In the absence of any comorbidities or acute illness, HPI documentation may be missing. The physician should remember to identify the details of the presenting problem: “Patient runs five miles daily. Knee felt unstable after running two weeks ago. Swelling and intermittent sharp pain 7/10. Patient has been taking ibuprofen daily without relief.”

Not medically necessary. Remember not to document any elements for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

Varying levels of history. E/M services are selected based on the content of the three “key” components: history, exam, and decision-making (or visit time). If counseling and/or coordination of care does not encompass >50% of the physician’s total visit time or the service is not exclusively designated as a time-based service (e.g. critical care and discharge day management), the physician’s service time is not considered.

Documentation for each of the three key components must support the reported visit level when reporting initial hospital care and consultations (for those payers who still recognize consultation codes). Subsequent hospital care (e.g. 99233) only requires supportive documentation from two key components. Medical decision-making should be one of the two supporting components in order to demonstrate the medical necessity and nature of the presenting problem; the other supporting component can be history or exam.

Each visit category (e.g. initial hospital care or subsequent hospital care) and service level (e.g. 99221-99233) identifies corresponding documentation requirements. Failure to document any essential element in a given visit level (e.g. family history required for a comprehensive history when billing for 99222 and 99223) may result in service denial or downcoding (e.g. 99221). Be aware of what an auditor expects when reviewing patient history (see Table 1).

There are four levels of history: problem-focused, expanded problem-focused, detailed, and comprehensive. An auditor determines the number of history elements documented in the progress note (see Table 2). The history level corresponds to the lowest documented element. For example, if physician documentation includes four HPI elements, eight ROS, and a comment in each of the PFSHs, the history level is equivalent to “detailed.” The history would support initial hospital care 99221 or subsequent hospital care 99233.

---

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Levinson DR. Department of Health and Human Services, Office of Inspector General: Coding Trends of Medicare Evaluation and Management Services. May 2012. Available at: oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. Accessed October 4, 2014.
2. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed October 4, 2014.
3. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. CPT 2013 Professional Edition (Current Procedural Terminology). Chicago: American Medical Association Press; 2012:4-10.
4. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed October 4, 2014.
5. Noridian Healthcare Solutions. Medicare Part B: Evaluation and Management Workshop Questions and Answers. Available at: www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkZpEVAyylqZyOfqel&tmpl=part_b_viewnews&style=part_ab_viewnews Accessed on October 4, 2014.
6. WPS Medicare Health Insurance. J5 MAC Part B: Documentation (Q&As). Available at: www.wpsmedicare.com/j5macpartb/resources/provider_types/evalmngmntqa.shtml. Accessed October 4, 2014.
7. NHIC, Corp. Building Your Medicare Knowledge: Advanced Building Blocks. Available at: www.medicarenhic.com/providers/pubs/AdvdBuildBlocks061212.pdf.
8. Palmetto GBA. Jurisdiction 11 Part B: History Component. Available at: www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Part%20B~EM%20Help%20Center~General%20Articles~History%20Component?open&Expand=1. Accessed October 4, 2014.
9. Novitas Solutions. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: https://www.novitas-solutions.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed October 4, 2014.

Hospitals with the highest rates of preventable adverse events will soon see their Medicare reimbursements cut by 1%.

The Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program (HACRP) is a product of the Affordable Care Act, implemented to tackle the high number of patients who experience avoidable, adverse—and too often fatal—medical events in the hospital; however, while patient safety has been a crucial issue for years, and one largely ignored by Congress until recently, some experts say the new metrics used to evaluate safety and penalize the bottom 25% of hospitals are imprecise and stand to punish those that serve the sickest patients and those that are among the most diligent about tracking patient safety.

“The biggest surprise was how big of a difference there was between academic medical centers and safety-net hospitals and everybody else,” says Ashish Jha, MD, MPH, hospitalist at the VA Boston Healthcare System, professor of health policy at the Harvard School of Public Health, and part of a team that recently used the CMS measures—patient safety indicators (PSI), central line-associated bloodstream infections (CLABSI), and catheter-associated urinary tract infections (CAUTI)—to evaluate where the nation’s hospitals might fall under HACRP.

In its analysis, Dr. Jha’s team found that major teaching hospitals are 2.9% more likely to be penalized under the program than nonteaching hospitals. Large, urban, public, teaching hospitals in the Northeast, with lots of poor patients, have a 62% chance of being penalized, compared to just a 9% chance for small, rural, for-profit, nonteaching hospitals in the South.

In 1998, the Institutes of Medicine estimated that nearly 100,000 patients die every year due to preventable medical errors. A recent estimate in the Journal of Patient Safety says this number may now be as high as 440,000.

In 2012, CMS reported that one in eight Medicare patients incurred a potentially avoidable complication while in the hospital, a 9% reduction from the previous baseline in 2010.

Patient safety clearly is an issue in the United States. But whether all of the HACRP metrics decided upon by CMS are appropriate is up for debate.

“PSI scores…were initially developed to look at healthcare trends broadly and not for comparing institutional performance,” says Ken Sands, MD, MPH, senior vice president of healthcare quality and chief quality officer at Beth Israel Deaconess Medical Center. “They were hijacked for that purpose, and a lot of the measures are based on administrative data.”

Dr. Sands, like Dr. Jha, is concerned that variation in the way hospitals code can influence the rate of adverse events reported through PSIs—which scan billing codes for hospital complications—without a clearly defined set of rules and without clearly defined language. Hospitals vary in how hard they look for complications and in how diligently they code, Dr. Jha says. Hospitals looking for safety issues are more likely to find and code for them, compared to less attentive institutions.

“It’s an inexpensive way to collect data nationally,” Dr. Sands says. “But whether we’re discriminating on quality is not that clear.”

Beth Israel ranks better than most U.S. hospitals on measures of mortality yet falls to the bottom quartile of the hospital-acquired condition (HAC) measures. The medical center may be penalized starting in October.

 

Although Dr. Sands says his colleagues continue to work to improve their CAUTI rates, an endeavor that preceded the CMS program, he is seeking better training for his coding staff and is working within the medical center’s electronic health record (EHR) to ensure accurate and consistent reporting.

At small, rural Nanticoke Memorial Hospital in southern Delaware, which is not at risk of HAC penalties next year, chief operating officer and chief nursing officer Penny Short says the hospital is currently adopting a “pretty robust” EHR to assist clinicians with early identification of sepsis and other risks. She says there is a lot more that EHRs can do to assist in patient safety, and hospitalists at her institution have been at the helm, driving progress.

It’s an approach Dr. Jha advocates for moving the needle forward in identifying better patient safety metrics. Meaningful use of EHRs provides clinically based, high quality metrics that can be captured far more effectively than the billing record, he says, offering an “automated approach as a routine part of the delivery of health care for tracking and potentially identifying adverse events.”

It’s up to physician leaders, Dr. Jha says—indeed, it is their moral responsibility—to encourage their CEOs to make these investments. And it’s something he believes CMS should get behind as well.

“Is this going to be cheap and easy? No,” Dr. Jha says. “Does CMS have the capacity to say hospitals have to invest? I think they do.

“I think we can do so much better. The opportunity to do so much better is right now.”

---

Kelly April Tyrrell is a freelance writer in Madison, Wis.

Hospitals with the highest rates of preventable adverse events will soon see their Medicare reimbursements cut by 1%.

The Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program (HACRP) is a product of the Affordable Care Act, implemented to tackle the high number of patients who experience avoidable, adverse—and too often fatal—medical events in the hospital; however, while patient safety has been a crucial issue for years, and one largely ignored by Congress until recently, some experts say the new metrics used to evaluate safety and penalize the bottom 25% of hospitals are imprecise and stand to punish those that serve the sickest patients and those that are among the most diligent about tracking patient safety.

“The biggest surprise was how big of a difference there was between academic medical centers and safety-net hospitals and everybody else,” says Ashish Jha, MD, MPH, hospitalist at the VA Boston Healthcare System, professor of health policy at the Harvard School of Public Health, and part of a team that recently used the CMS measures—patient safety indicators (PSI), central line-associated bloodstream infections (CLABSI), and catheter-associated urinary tract infections (CAUTI)—to evaluate where the nation’s hospitals might fall under HACRP.

In its analysis, Dr. Jha’s team found that major teaching hospitals are 2.9% more likely to be penalized under the program than nonteaching hospitals. Large, urban, public, teaching hospitals in the Northeast, with lots of poor patients, have a 62% chance of being penalized, compared to just a 9% chance for small, rural, for-profit, nonteaching hospitals in the South.

In 1998, the Institutes of Medicine estimated that nearly 100,000 patients die every year due to preventable medical errors. A recent estimate in the Journal of Patient Safety says this number may now be as high as 440,000.

In 2012, CMS reported that one in eight Medicare patients incurred a potentially avoidable complication while in the hospital, a 9% reduction from the previous baseline in 2010.

Patient safety clearly is an issue in the United States. But whether all of the HACRP metrics decided upon by CMS are appropriate is up for debate.

“PSI scores…were initially developed to look at healthcare trends broadly and not for comparing institutional performance,” says Ken Sands, MD, MPH, senior vice president of healthcare quality and chief quality officer at Beth Israel Deaconess Medical Center. “They were hijacked for that purpose, and a lot of the measures are based on administrative data.”

Dr. Sands, like Dr. Jha, is concerned that variation in the way hospitals code can influence the rate of adverse events reported through PSIs—which scan billing codes for hospital complications—without a clearly defined set of rules and without clearly defined language. Hospitals vary in how hard they look for complications and in how diligently they code, Dr. Jha says. Hospitals looking for safety issues are more likely to find and code for them, compared to less attentive institutions.

“It’s an inexpensive way to collect data nationally,” Dr. Sands says. “But whether we’re discriminating on quality is not that clear.”

Beth Israel ranks better than most U.S. hospitals on measures of mortality yet falls to the bottom quartile of the hospital-acquired condition (HAC) measures. The medical center may be penalized starting in October.

 

Although Dr. Sands says his colleagues continue to work to improve their CAUTI rates, an endeavor that preceded the CMS program, he is seeking better training for his coding staff and is working within the medical center’s electronic health record (EHR) to ensure accurate and consistent reporting.

At small, rural Nanticoke Memorial Hospital in southern Delaware, which is not at risk of HAC penalties next year, chief operating officer and chief nursing officer Penny Short says the hospital is currently adopting a “pretty robust” EHR to assist clinicians with early identification of sepsis and other risks. She says there is a lot more that EHRs can do to assist in patient safety, and hospitalists at her institution have been at the helm, driving progress.

It’s an approach Dr. Jha advocates for moving the needle forward in identifying better patient safety metrics. Meaningful use of EHRs provides clinically based, high quality metrics that can be captured far more effectively than the billing record, he says, offering an “automated approach as a routine part of the delivery of health care for tracking and potentially identifying adverse events.”

It’s up to physician leaders, Dr. Jha says—indeed, it is their moral responsibility—to encourage their CEOs to make these investments. And it’s something he believes CMS should get behind as well.

“Is this going to be cheap and easy? No,” Dr. Jha says. “Does CMS have the capacity to say hospitals have to invest? I think they do.

“I think we can do so much better. The opportunity to do so much better is right now.”

---

Kelly April Tyrrell is a freelance writer in Madison, Wis.

Hospitals with the highest rates of preventable adverse events will soon see their Medicare reimbursements cut by 1%.

The Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program (HACRP) is a product of the Affordable Care Act, implemented to tackle the high number of patients who experience avoidable, adverse—and too often fatal—medical events in the hospital; however, while patient safety has been a crucial issue for years, and one largely ignored by Congress until recently, some experts say the new metrics used to evaluate safety and penalize the bottom 25% of hospitals are imprecise and stand to punish those that serve the sickest patients and those that are among the most diligent about tracking patient safety.

“The biggest surprise was how big of a difference there was between academic medical centers and safety-net hospitals and everybody else,” says Ashish Jha, MD, MPH, hospitalist at the VA Boston Healthcare System, professor of health policy at the Harvard School of Public Health, and part of a team that recently used the CMS measures—patient safety indicators (PSI), central line-associated bloodstream infections (CLABSI), and catheter-associated urinary tract infections (CAUTI)—to evaluate where the nation’s hospitals might fall under HACRP.

In its analysis, Dr. Jha’s team found that major teaching hospitals are 2.9% more likely to be penalized under the program than nonteaching hospitals. Large, urban, public, teaching hospitals in the Northeast, with lots of poor patients, have a 62% chance of being penalized, compared to just a 9% chance for small, rural, for-profit, nonteaching hospitals in the South.

In 1998, the Institutes of Medicine estimated that nearly 100,000 patients die every year due to preventable medical errors. A recent estimate in the Journal of Patient Safety says this number may now be as high as 440,000.

In 2012, CMS reported that one in eight Medicare patients incurred a potentially avoidable complication while in the hospital, a 9% reduction from the previous baseline in 2010.

Patient safety clearly is an issue in the United States. But whether all of the HACRP metrics decided upon by CMS are appropriate is up for debate.

“PSI scores…were initially developed to look at healthcare trends broadly and not for comparing institutional performance,” says Ken Sands, MD, MPH, senior vice president of healthcare quality and chief quality officer at Beth Israel Deaconess Medical Center. “They were hijacked for that purpose, and a lot of the measures are based on administrative data.”

Dr. Sands, like Dr. Jha, is concerned that variation in the way hospitals code can influence the rate of adverse events reported through PSIs—which scan billing codes for hospital complications—without a clearly defined set of rules and without clearly defined language. Hospitals vary in how hard they look for complications and in how diligently they code, Dr. Jha says. Hospitals looking for safety issues are more likely to find and code for them, compared to less attentive institutions.

“It’s an inexpensive way to collect data nationally,” Dr. Sands says. “But whether we’re discriminating on quality is not that clear.”

Beth Israel ranks better than most U.S. hospitals on measures of mortality yet falls to the bottom quartile of the hospital-acquired condition (HAC) measures. The medical center may be penalized starting in October.

 

Although Dr. Sands says his colleagues continue to work to improve their CAUTI rates, an endeavor that preceded the CMS program, he is seeking better training for his coding staff and is working within the medical center’s electronic health record (EHR) to ensure accurate and consistent reporting.

At small, rural Nanticoke Memorial Hospital in southern Delaware, which is not at risk of HAC penalties next year, chief operating officer and chief nursing officer Penny Short says the hospital is currently adopting a “pretty robust” EHR to assist clinicians with early identification of sepsis and other risks. She says there is a lot more that EHRs can do to assist in patient safety, and hospitalists at her institution have been at the helm, driving progress.

It’s an approach Dr. Jha advocates for moving the needle forward in identifying better patient safety metrics. Meaningful use of EHRs provides clinically based, high quality metrics that can be captured far more effectively than the billing record, he says, offering an “automated approach as a routine part of the delivery of health care for tracking and potentially identifying adverse events.”

It’s up to physician leaders, Dr. Jha says—indeed, it is their moral responsibility—to encourage their CEOs to make these investments. And it’s something he believes CMS should get behind as well.

“Is this going to be cheap and easy? No,” Dr. Jha says. “Does CMS have the capacity to say hospitals have to invest? I think they do.

“I think we can do so much better. The opportunity to do so much better is right now.”

---

Kelly April Tyrrell is a freelance writer in Madison, Wis.

Case

A 45-year-old previously healthy female was admitted to the ICU with sepsis caused by community-acquired pneumonia. Per hospital policy, all patients admitted to the ICU are screened for MRSA colonization. If the nasal screen is positive, contact isolation is initiated and the hospital’s MRSA decolonization protocol is implemented. Her nasal screen was positive for MRSA.

Overview

MRSA infections are associated with significant morbidity and mortality, and death occurs in almost 5% of patients who develop a MRSA infection. In 2005, invasive MRSA was responsible for approximately 278,000 hospitalizations and 19,000 deaths. MRSA is a common cause of healthcare-associated infections (HAIs) and is the most common pathogen in surgical site infections (SSIs) and ventilator-associated pneumonias. The cost of treating MRSA infections is substantial; in 2003, $14.5 billion was spent on MRSA-related hospitalizations.

It is well known that MRSA colonization is a risk factor for the subsequent development of a MRSA infection. This risk persists over time, and approximately 25% of individuals who are colonized with MRSA for more than one year will develop a late-onset MRSA infection.¹ It is estimated that between 0.8% and 6% of people in the U.S. are asymptomatically colonized with MRSA.

One infection control strategy for reducing the transmission of MRSA among hospitalized patients involves screening for the presence of this organism and then placing colonized and/or infected patients in isolation; however, there is considerable controversy about which patients should be screened.

An additional element of many infection control strategies involves MRSA decolonization, but there is uncertainty about which patients benefit from it and significant variability in its reported success rates.² Additionally, several studies have indicated that MRSA decolonization is only temporary and that patients become recolonized over time.

Treatment

It is estimated that 10% to 20% of MRSA carriers will develop an infection while they are hospitalized. Furthermore, even after they have been discharged from the hospital, their risk for developing a MRSA infection persists.

Most patients who develop a MRSA infection have been colonized prior to infection, and these patients usually develop an infection caused by the same strain as the colonization. In view of this fact, a primary goal of decolonization is reducing the likelihood of “auto-infection.” Another goal of decolonization is reducing the transmission of MRSA to other patients.

In order to determine whether MRSA colonization is present, patients undergo screening, and specimens are collected from the nares using nasal swabs. Specimens from extranasal sites, such as the groin, are sometimes also obtained for screening. These screening tests are usually done with either cultures or polymerase chain reaction testing.

There is significant variability in the details of screening and decolonization protocols among different healthcare facilities. Typically, the screening test costs more than the agents used for decolonization. Partly for this reason, some facilities forego screening altogether, instead treating all patients with a decolonization regimen; however, there is concern that administering decolonizing medications to all patients would lead to the unnecessary treatment of large numbers of patients. Such widespread use of the decolonizing agents might promote the development of resistance to these medications.

Medications. Decolonization typically involves the use of a topical antibiotic, most commonly mupirocin, which is applied to the nares. This may be used in conjunction with an oral antimicrobial agent. While the nares are the anatomical locations most commonly colonized by MRSA, extranasal colonization occurs in 50% of those who are nasally colonized.

 

Of the topical medications available for decolonization, mupirocin has the highest efficacy, with eradication of MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) colonization ranging from 81% to 93%. To increase the likelihood of successful decolonization, an antiseptic agent, such as chlorhexidine gluconate, may also be applied to the skin. Chlorhexidine gluconate is also commonly used to prevent other HAIs.

Neomycin is sometimes used for decolonization, but its efficacy for this purpose is questionable. There are also concerns about resistance, but it may be an option in cases of documented mupirocin resistance. Preparations that contain tea tree oil appear to be more effective for decolonization of skin sites than for nasal decolonization. Table 1 lists the topical antibiotics and antiseptics that may be utilized for decolonization, while Table 2 lists the oral medications that can be used for this purpose. Table 3 lists investigational agents being evaluated for their ability to decolonize patients.

It has been suggested that the patients who might derive the most benefit from decolonization are those at increased risk for developing a MRSA infection during a specific time interval. This would include patients who are admitted to the ICU for an acute illness and cardiothoracic surgery patients. A benefit from decolonization has also been observed in hemodialysis patients, who have an incidence of invasive MRSA infections 100 times greater than the general population. Otherwise, there are no data to support the routine use of decolonization in nonsurgical patients.

It is not uncommon for hospitals to screen patients admitted to the ICU for MRSA nasal colonization; in fact, screening is mandatory in nine states. If the nasal screen is positive, contact precautions are instituted. The decision about whether or not to initiate a decolonization protocol varies among different ICUs, but most do not carry out universal decolonization.

Some studies show decolonization is beneficial for ICU patients. These studies include a large cluster-randomized trial called REDUCE MRSA,³ which took place in 43 hospitals and involved 74,256 patients in 74 ICUs. The study showed that universal (i.e., without screening) decolonization using mupirocin and chlorhexidine was effective in reducing rates of MRSA clinical isolates, as well as bloodstream infection from any pathogen. Other studies have demonstrated benefits from the decolonization of ICU patients.^4,5

Surgical Site Infections. Meanwhile, SSIs are often associated with increased mortality rates and substantial healthcare costs, including increased hospital lengths of stay and readmission rates. Staphylococcus aureus is the pathogen most commonly isolated from SSIs. In surgical patients, colonization with MRSA is associated with an elevated rate of MRSA SSIs. The goal of decolonization in surgical patients is not to permanently eliminate MRSA but to prevent SSIs by suppressing the presence of this organism for a relatively brief duration.

There is evidence that decolonization reduces SSIs for cardiothoracic surgeries.⁶ For these patients, it is cost effective to screen for nasal carriage of MRSA and then treat carriers with a combination of pre-operative mupirocin and chlorhexidine. It may be reasonable to delay cardiothoracic surgery in colonized patients who will require implantation of prosthetic material until they complete MRSA decolonization.

In addition to reducing the risk of auto-infection, another goal of decolonization is limiting the possibility of transmission of MRSA from a colonized patient to a susceptible individual; however, there are only limited data available that measure the efficacy of decolonization for preventing transmission.

Concerns about the potential hazards of decolonization therapy have impacted its widespread implementation. The biggest concern is that patients may develop resistance to the antimicrobial agents used for decolonization, particularly if they are used at increased frequency. Mupirocin resistance monitoring is valuable, but, unfortunately, the susceptibility of Staphylococcus aureus to mupirocin is not routinely evaluated, so the prevalence of mupirocin resistance in local strains is often unknown. Another concern about decolonization is the cost of screening and decolonizing patients.

 

Back to the Case

The patient in this case required admission to an ICU and, based on the results of the REDUCE MRSA clinical trial, she would likely benefit from undergoing decolonization to reduce her risk of both MRSA-positive clinical cultures and bloodstream infections caused by any pathogen.

Bottom Line

Decolonization is beneficial for patients at increased risk of developing a MRSA infection during a specific period, such as patients admitted to the ICU and those undergoing cardiothoracic surgery.

---

Dr. Clarke is assistant professor in the division of hospital medicine at Emory University Hospital and a faculty member in the Emory University Department of Medicine, both in Atlanta.

References

1. Dow G, Field D, Mancuso M, Allard J. Decolonization of methicillin-resistant Staphylococcus aureus during routine hospital care: Efficacy and long-term follow-up. Can J Infect Dis Med Microbiol. 2010;21(1):38-44.
2. Simor AE. Staphylococcal decolonisation: An effective strategy for prevention of infection? Lancet Infect Dis. 2011;11(12):952-962.
3. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.
4. Fraser T, Fatica C, Scarpelli M, et al. Decrease in Staphylococcus aureus colonization and hospital-acquired infection in a medical intensive care unit after institution of an active surveillance and decolonization program. Infect Control Hosp Epidemiol. 2010;31(8):779-783.
5. Robotham J, Graves N, Cookson B, et al. Screening, isolation, and decolonisation strategies in the control of methicillin-resistant Staphylococcus aureus in intensive care units: Cost effectiveness evaluation. BMJ. 2011;343:d5694.
6. Schweizer M, Perencevich E, McDanel J, et al. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: Systematic review and meta-analysis. BMJ. 2013;346:f2743.

Case

A 45-year-old previously healthy female was admitted to the ICU with sepsis caused by community-acquired pneumonia. Per hospital policy, all patients admitted to the ICU are screened for MRSA colonization. If the nasal screen is positive, contact isolation is initiated and the hospital’s MRSA decolonization protocol is implemented. Her nasal screen was positive for MRSA.

Overview

MRSA infections are associated with significant morbidity and mortality, and death occurs in almost 5% of patients who develop a MRSA infection. In 2005, invasive MRSA was responsible for approximately 278,000 hospitalizations and 19,000 deaths. MRSA is a common cause of healthcare-associated infections (HAIs) and is the most common pathogen in surgical site infections (SSIs) and ventilator-associated pneumonias. The cost of treating MRSA infections is substantial; in 2003, $14.5 billion was spent on MRSA-related hospitalizations.

It is well known that MRSA colonization is a risk factor for the subsequent development of a MRSA infection. This risk persists over time, and approximately 25% of individuals who are colonized with MRSA for more than one year will develop a late-onset MRSA infection.¹ It is estimated that between 0.8% and 6% of people in the U.S. are asymptomatically colonized with MRSA.

One infection control strategy for reducing the transmission of MRSA among hospitalized patients involves screening for the presence of this organism and then placing colonized and/or infected patients in isolation; however, there is considerable controversy about which patients should be screened.

An additional element of many infection control strategies involves MRSA decolonization, but there is uncertainty about which patients benefit from it and significant variability in its reported success rates.² Additionally, several studies have indicated that MRSA decolonization is only temporary and that patients become recolonized over time.

Treatment

It is estimated that 10% to 20% of MRSA carriers will develop an infection while they are hospitalized. Furthermore, even after they have been discharged from the hospital, their risk for developing a MRSA infection persists.

Most patients who develop a MRSA infection have been colonized prior to infection, and these patients usually develop an infection caused by the same strain as the colonization. In view of this fact, a primary goal of decolonization is reducing the likelihood of “auto-infection.” Another goal of decolonization is reducing the transmission of MRSA to other patients.

In order to determine whether MRSA colonization is present, patients undergo screening, and specimens are collected from the nares using nasal swabs. Specimens from extranasal sites, such as the groin, are sometimes also obtained for screening. These screening tests are usually done with either cultures or polymerase chain reaction testing.

There is significant variability in the details of screening and decolonization protocols among different healthcare facilities. Typically, the screening test costs more than the agents used for decolonization. Partly for this reason, some facilities forego screening altogether, instead treating all patients with a decolonization regimen; however, there is concern that administering decolonizing medications to all patients would lead to the unnecessary treatment of large numbers of patients. Such widespread use of the decolonizing agents might promote the development of resistance to these medications.

Medications. Decolonization typically involves the use of a topical antibiotic, most commonly mupirocin, which is applied to the nares. This may be used in conjunction with an oral antimicrobial agent. While the nares are the anatomical locations most commonly colonized by MRSA, extranasal colonization occurs in 50% of those who are nasally colonized.

 

Of the topical medications available for decolonization, mupirocin has the highest efficacy, with eradication of MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) colonization ranging from 81% to 93%. To increase the likelihood of successful decolonization, an antiseptic agent, such as chlorhexidine gluconate, may also be applied to the skin. Chlorhexidine gluconate is also commonly used to prevent other HAIs.

Neomycin is sometimes used for decolonization, but its efficacy for this purpose is questionable. There are also concerns about resistance, but it may be an option in cases of documented mupirocin resistance. Preparations that contain tea tree oil appear to be more effective for decolonization of skin sites than for nasal decolonization. Table 1 lists the topical antibiotics and antiseptics that may be utilized for decolonization, while Table 2 lists the oral medications that can be used for this purpose. Table 3 lists investigational agents being evaluated for their ability to decolonize patients.

It has been suggested that the patients who might derive the most benefit from decolonization are those at increased risk for developing a MRSA infection during a specific time interval. This would include patients who are admitted to the ICU for an acute illness and cardiothoracic surgery patients. A benefit from decolonization has also been observed in hemodialysis patients, who have an incidence of invasive MRSA infections 100 times greater than the general population. Otherwise, there are no data to support the routine use of decolonization in nonsurgical patients.

It is not uncommon for hospitals to screen patients admitted to the ICU for MRSA nasal colonization; in fact, screening is mandatory in nine states. If the nasal screen is positive, contact precautions are instituted. The decision about whether or not to initiate a decolonization protocol varies among different ICUs, but most do not carry out universal decolonization.

Some studies show decolonization is beneficial for ICU patients. These studies include a large cluster-randomized trial called REDUCE MRSA,³ which took place in 43 hospitals and involved 74,256 patients in 74 ICUs. The study showed that universal (i.e., without screening) decolonization using mupirocin and chlorhexidine was effective in reducing rates of MRSA clinical isolates, as well as bloodstream infection from any pathogen. Other studies have demonstrated benefits from the decolonization of ICU patients.^4,5

Surgical Site Infections. Meanwhile, SSIs are often associated with increased mortality rates and substantial healthcare costs, including increased hospital lengths of stay and readmission rates. Staphylococcus aureus is the pathogen most commonly isolated from SSIs. In surgical patients, colonization with MRSA is associated with an elevated rate of MRSA SSIs. The goal of decolonization in surgical patients is not to permanently eliminate MRSA but to prevent SSIs by suppressing the presence of this organism for a relatively brief duration.

There is evidence that decolonization reduces SSIs for cardiothoracic surgeries.⁶ For these patients, it is cost effective to screen for nasal carriage of MRSA and then treat carriers with a combination of pre-operative mupirocin and chlorhexidine. It may be reasonable to delay cardiothoracic surgery in colonized patients who will require implantation of prosthetic material until they complete MRSA decolonization.

In addition to reducing the risk of auto-infection, another goal of decolonization is limiting the possibility of transmission of MRSA from a colonized patient to a susceptible individual; however, there are only limited data available that measure the efficacy of decolonization for preventing transmission.

Concerns about the potential hazards of decolonization therapy have impacted its widespread implementation. The biggest concern is that patients may develop resistance to the antimicrobial agents used for decolonization, particularly if they are used at increased frequency. Mupirocin resistance monitoring is valuable, but, unfortunately, the susceptibility of Staphylococcus aureus to mupirocin is not routinely evaluated, so the prevalence of mupirocin resistance in local strains is often unknown. Another concern about decolonization is the cost of screening and decolonizing patients.

 

Back to the Case

The patient in this case required admission to an ICU and, based on the results of the REDUCE MRSA clinical trial, she would likely benefit from undergoing decolonization to reduce her risk of both MRSA-positive clinical cultures and bloodstream infections caused by any pathogen.

Bottom Line

Decolonization is beneficial for patients at increased risk of developing a MRSA infection during a specific period, such as patients admitted to the ICU and those undergoing cardiothoracic surgery.

---

Dr. Clarke is assistant professor in the division of hospital medicine at Emory University Hospital and a faculty member in the Emory University Department of Medicine, both in Atlanta.

References

1. Dow G, Field D, Mancuso M, Allard J. Decolonization of methicillin-resistant Staphylococcus aureus during routine hospital care: Efficacy and long-term follow-up. Can J Infect Dis Med Microbiol. 2010;21(1):38-44.
2. Simor AE. Staphylococcal decolonisation: An effective strategy for prevention of infection? Lancet Infect Dis. 2011;11(12):952-962.
3. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.
4. Fraser T, Fatica C, Scarpelli M, et al. Decrease in Staphylococcus aureus colonization and hospital-acquired infection in a medical intensive care unit after institution of an active surveillance and decolonization program. Infect Control Hosp Epidemiol. 2010;31(8):779-783.
5. Robotham J, Graves N, Cookson B, et al. Screening, isolation, and decolonisation strategies in the control of methicillin-resistant Staphylococcus aureus in intensive care units: Cost effectiveness evaluation. BMJ. 2011;343:d5694.
6. Schweizer M, Perencevich E, McDanel J, et al. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: Systematic review and meta-analysis. BMJ. 2013;346:f2743.

Case

A 45-year-old previously healthy female was admitted to the ICU with sepsis caused by community-acquired pneumonia. Per hospital policy, all patients admitted to the ICU are screened for MRSA colonization. If the nasal screen is positive, contact isolation is initiated and the hospital’s MRSA decolonization protocol is implemented. Her nasal screen was positive for MRSA.

Overview

MRSA infections are associated with significant morbidity and mortality, and death occurs in almost 5% of patients who develop a MRSA infection. In 2005, invasive MRSA was responsible for approximately 278,000 hospitalizations and 19,000 deaths. MRSA is a common cause of healthcare-associated infections (HAIs) and is the most common pathogen in surgical site infections (SSIs) and ventilator-associated pneumonias. The cost of treating MRSA infections is substantial; in 2003, $14.5 billion was spent on MRSA-related hospitalizations.

It is well known that MRSA colonization is a risk factor for the subsequent development of a MRSA infection. This risk persists over time, and approximately 25% of individuals who are colonized with MRSA for more than one year will develop a late-onset MRSA infection.¹ It is estimated that between 0.8% and 6% of people in the U.S. are asymptomatically colonized with MRSA.

One infection control strategy for reducing the transmission of MRSA among hospitalized patients involves screening for the presence of this organism and then placing colonized and/or infected patients in isolation; however, there is considerable controversy about which patients should be screened.

An additional element of many infection control strategies involves MRSA decolonization, but there is uncertainty about which patients benefit from it and significant variability in its reported success rates.² Additionally, several studies have indicated that MRSA decolonization is only temporary and that patients become recolonized over time.

Treatment

It is estimated that 10% to 20% of MRSA carriers will develop an infection while they are hospitalized. Furthermore, even after they have been discharged from the hospital, their risk for developing a MRSA infection persists.

Most patients who develop a MRSA infection have been colonized prior to infection, and these patients usually develop an infection caused by the same strain as the colonization. In view of this fact, a primary goal of decolonization is reducing the likelihood of “auto-infection.” Another goal of decolonization is reducing the transmission of MRSA to other patients.

In order to determine whether MRSA colonization is present, patients undergo screening, and specimens are collected from the nares using nasal swabs. Specimens from extranasal sites, such as the groin, are sometimes also obtained for screening. These screening tests are usually done with either cultures or polymerase chain reaction testing.

There is significant variability in the details of screening and decolonization protocols among different healthcare facilities. Typically, the screening test costs more than the agents used for decolonization. Partly for this reason, some facilities forego screening altogether, instead treating all patients with a decolonization regimen; however, there is concern that administering decolonizing medications to all patients would lead to the unnecessary treatment of large numbers of patients. Such widespread use of the decolonizing agents might promote the development of resistance to these medications.

Medications. Decolonization typically involves the use of a topical antibiotic, most commonly mupirocin, which is applied to the nares. This may be used in conjunction with an oral antimicrobial agent. While the nares are the anatomical locations most commonly colonized by MRSA, extranasal colonization occurs in 50% of those who are nasally colonized.

 

Of the topical medications available for decolonization, mupirocin has the highest efficacy, with eradication of MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) colonization ranging from 81% to 93%. To increase the likelihood of successful decolonization, an antiseptic agent, such as chlorhexidine gluconate, may also be applied to the skin. Chlorhexidine gluconate is also commonly used to prevent other HAIs.

Neomycin is sometimes used for decolonization, but its efficacy for this purpose is questionable. There are also concerns about resistance, but it may be an option in cases of documented mupirocin resistance. Preparations that contain tea tree oil appear to be more effective for decolonization of skin sites than for nasal decolonization. Table 1 lists the topical antibiotics and antiseptics that may be utilized for decolonization, while Table 2 lists the oral medications that can be used for this purpose. Table 3 lists investigational agents being evaluated for their ability to decolonize patients.

It has been suggested that the patients who might derive the most benefit from decolonization are those at increased risk for developing a MRSA infection during a specific time interval. This would include patients who are admitted to the ICU for an acute illness and cardiothoracic surgery patients. A benefit from decolonization has also been observed in hemodialysis patients, who have an incidence of invasive MRSA infections 100 times greater than the general population. Otherwise, there are no data to support the routine use of decolonization in nonsurgical patients.

It is not uncommon for hospitals to screen patients admitted to the ICU for MRSA nasal colonization; in fact, screening is mandatory in nine states. If the nasal screen is positive, contact precautions are instituted. The decision about whether or not to initiate a decolonization protocol varies among different ICUs, but most do not carry out universal decolonization.

Some studies show decolonization is beneficial for ICU patients. These studies include a large cluster-randomized trial called REDUCE MRSA,³ which took place in 43 hospitals and involved 74,256 patients in 74 ICUs. The study showed that universal (i.e., without screening) decolonization using mupirocin and chlorhexidine was effective in reducing rates of MRSA clinical isolates, as well as bloodstream infection from any pathogen. Other studies have demonstrated benefits from the decolonization of ICU patients.^4,5

Surgical Site Infections. Meanwhile, SSIs are often associated with increased mortality rates and substantial healthcare costs, including increased hospital lengths of stay and readmission rates. Staphylococcus aureus is the pathogen most commonly isolated from SSIs. In surgical patients, colonization with MRSA is associated with an elevated rate of MRSA SSIs. The goal of decolonization in surgical patients is not to permanently eliminate MRSA but to prevent SSIs by suppressing the presence of this organism for a relatively brief duration.

There is evidence that decolonization reduces SSIs for cardiothoracic surgeries.⁶ For these patients, it is cost effective to screen for nasal carriage of MRSA and then treat carriers with a combination of pre-operative mupirocin and chlorhexidine. It may be reasonable to delay cardiothoracic surgery in colonized patients who will require implantation of prosthetic material until they complete MRSA decolonization.

In addition to reducing the risk of auto-infection, another goal of decolonization is limiting the possibility of transmission of MRSA from a colonized patient to a susceptible individual; however, there are only limited data available that measure the efficacy of decolonization for preventing transmission.

Concerns about the potential hazards of decolonization therapy have impacted its widespread implementation. The biggest concern is that patients may develop resistance to the antimicrobial agents used for decolonization, particularly if they are used at increased frequency. Mupirocin resistance monitoring is valuable, but, unfortunately, the susceptibility of Staphylococcus aureus to mupirocin is not routinely evaluated, so the prevalence of mupirocin resistance in local strains is often unknown. Another concern about decolonization is the cost of screening and decolonizing patients.

 

Back to the Case

The patient in this case required admission to an ICU and, based on the results of the REDUCE MRSA clinical trial, she would likely benefit from undergoing decolonization to reduce her risk of both MRSA-positive clinical cultures and bloodstream infections caused by any pathogen.

Bottom Line

Decolonization is beneficial for patients at increased risk of developing a MRSA infection during a specific period, such as patients admitted to the ICU and those undergoing cardiothoracic surgery.

---

Dr. Clarke is assistant professor in the division of hospital medicine at Emory University Hospital and a faculty member in the Emory University Department of Medicine, both in Atlanta.

References

1. Dow G, Field D, Mancuso M, Allard J. Decolonization of methicillin-resistant Staphylococcus aureus during routine hospital care: Efficacy and long-term follow-up. Can J Infect Dis Med Microbiol. 2010;21(1):38-44.
2. Simor AE. Staphylococcal decolonisation: An effective strategy for prevention of infection? Lancet Infect Dis. 2011;11(12):952-962.
3. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.
4. Fraser T, Fatica C, Scarpelli M, et al. Decrease in Staphylococcus aureus colonization and hospital-acquired infection in a medical intensive care unit after institution of an active surveillance and decolonization program. Infect Control Hosp Epidemiol. 2010;31(8):779-783.
5. Robotham J, Graves N, Cookson B, et al. Screening, isolation, and decolonisation strategies in the control of methicillin-resistant Staphylococcus aureus in intensive care units: Cost effectiveness evaluation. BMJ. 2011;343:d5694.
6. Schweizer M, Perencevich E, McDanel J, et al. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infections after cardiac or orthopedic surgery: Systematic review and meta-analysis. BMJ. 2013;346:f2743.

I think my team of hospitalists is probably tired of hearing my sports analogies. But as I look at the State of Hospital Medicine 2014 report (SOHM), I cannot help but see relationships to athletics.

When you think about football, you automatically contemplate the scope of a particular team and the context of the upcoming season. What are the strengths of the team—do we emphasize offense or defense or special teams? How about the variety of formations or the scheduling and strength of opponents? How about the depth of our roster—what is the talent level available? How do we compare to other teams?

How in the world does this relate to the SOHM? It gives us a chance to evaluate our own hospital medicine groups (HMGs) in the context of the other HMGs across the country. When I look at scope of services and, particularly, the data from Figure 3.1, I am struck with the breadth of the range of services in which HMGs engage. Certainly, our core identity as hospitalists includes admitting referral patients and unassigned patients, but, as of 2014, nearly 90% of hospitalist groups are also managing and co-managing surgical and medical subspecialty patients. To my eyes, the big change since 2012 is the 20% increase in the number of HMGs medically co-managing medical subspecialty patients.

There are some newcomers to our roster, as well—the palliative care and post-acute care work being done by 15% and 25% of our groups, respectively. Particularly striking is the fact that one quarter of HMGs are involved in post-acute care, follow-up clinics, nursing homes, and the like.

My take on this is that factors such as increased complexity of hospitalized patients with lean length of stay and higher acuity needs at discharge transition are driving the need for a measure of continuity and expertise post discharge that may best be provided by HMGs. The trending of the post-acute care challenges/opportunities will certainly be worth watching—sort of like a rookie player who is having a big impact.

Not surprisingly, nighttime admissions work continues to gain traction. Nearly 60% of HMGs are performing nighttime admissions.

In my regional chapter, we recently heard a presentation on “nocturnists.” An interesting contention that caught my attention was that the nocturnist viewed herself as providing expert clinical care during off-hours—particularly at night—and that she was looking to increase the value and not just “put her finger in the dike,” so to speak, until the cavalry arrived at daybreak. As HMG responsibilities increase during the off-hours, I am thinking that my colleague is right: We are going to have to increase our depth and strength at this particular position so that we might actually become known as the “nighttime experts.” I look for this trend to continue.

Finally, I am drawn to the data on care of patients in the ICU, a number that continues to rise—almost 70% of HMGs now. Meanwhile, procedures have dipped to 33% from 53% in the last report. At first, it seemed a little bit puzzling to me that as involvement in the ICUs seemed to increase, procedures diminished. My anecdotal experience is that most of my procedures occurred on patients who had intensive care requirements. Nonetheless, many hospitalists I have talked to seem to believe that the requirement/expectation of imaging in the performance of more and more invasive procedures—now a standard of care— has increasingly driven procedures to specialized areas of the hospital such as imaging/radiology departments. There may also be a net decrease in the number of procedures performed as more noninvasive diagnostic modalities provide satisfactory information.

 

As hospitalists may become focused on throughput (admissions discharges and transfers), the interruption to perform procedures may decrease the net value of the hospitalist to the institution. It may make sense for others to be doing procedures. Whatever the cause, my guess is these two trends may continue.

Diving deeper into the granularity of the report will lead the reader to discover subtle differences and trends. Academics, pediatric hospitalists, and independent HMGs all have some nuances, not to mention regional variation. You will have to dig into the report yourself to explore.

Just as there is a freshness to every new sports season, there is a freshness to reviewing the information from the SOHM reports, and evaluating the scope of service is always an exciting moment.

---

Dr. Landis is medical director of Wellspan Hospitalists in York, Pa., and a member of SHM’s Practice Analysis Committee.

I think my team of hospitalists is probably tired of hearing my sports analogies. But as I look at the State of Hospital Medicine 2014 report (SOHM), I cannot help but see relationships to athletics.

When you think about football, you automatically contemplate the scope of a particular team and the context of the upcoming season. What are the strengths of the team—do we emphasize offense or defense or special teams? How about the variety of formations or the scheduling and strength of opponents? How about the depth of our roster—what is the talent level available? How do we compare to other teams?

How in the world does this relate to the SOHM? It gives us a chance to evaluate our own hospital medicine groups (HMGs) in the context of the other HMGs across the country. When I look at scope of services and, particularly, the data from Figure 3.1, I am struck with the breadth of the range of services in which HMGs engage. Certainly, our core identity as hospitalists includes admitting referral patients and unassigned patients, but, as of 2014, nearly 90% of hospitalist groups are also managing and co-managing surgical and medical subspecialty patients. To my eyes, the big change since 2012 is the 20% increase in the number of HMGs medically co-managing medical subspecialty patients.

There are some newcomers to our roster, as well—the palliative care and post-acute care work being done by 15% and 25% of our groups, respectively. Particularly striking is the fact that one quarter of HMGs are involved in post-acute care, follow-up clinics, nursing homes, and the like.

My take on this is that factors such as increased complexity of hospitalized patients with lean length of stay and higher acuity needs at discharge transition are driving the need for a measure of continuity and expertise post discharge that may best be provided by HMGs. The trending of the post-acute care challenges/opportunities will certainly be worth watching—sort of like a rookie player who is having a big impact.

Not surprisingly, nighttime admissions work continues to gain traction. Nearly 60% of HMGs are performing nighttime admissions.

In my regional chapter, we recently heard a presentation on “nocturnists.” An interesting contention that caught my attention was that the nocturnist viewed herself as providing expert clinical care during off-hours—particularly at night—and that she was looking to increase the value and not just “put her finger in the dike,” so to speak, until the cavalry arrived at daybreak. As HMG responsibilities increase during the off-hours, I am thinking that my colleague is right: We are going to have to increase our depth and strength at this particular position so that we might actually become known as the “nighttime experts.” I look for this trend to continue.

Finally, I am drawn to the data on care of patients in the ICU, a number that continues to rise—almost 70% of HMGs now. Meanwhile, procedures have dipped to 33% from 53% in the last report. At first, it seemed a little bit puzzling to me that as involvement in the ICUs seemed to increase, procedures diminished. My anecdotal experience is that most of my procedures occurred on patients who had intensive care requirements. Nonetheless, many hospitalists I have talked to seem to believe that the requirement/expectation of imaging in the performance of more and more invasive procedures—now a standard of care— has increasingly driven procedures to specialized areas of the hospital such as imaging/radiology departments. There may also be a net decrease in the number of procedures performed as more noninvasive diagnostic modalities provide satisfactory information.

 

As hospitalists may become focused on throughput (admissions discharges and transfers), the interruption to perform procedures may decrease the net value of the hospitalist to the institution. It may make sense for others to be doing procedures. Whatever the cause, my guess is these two trends may continue.

Diving deeper into the granularity of the report will lead the reader to discover subtle differences and trends. Academics, pediatric hospitalists, and independent HMGs all have some nuances, not to mention regional variation. You will have to dig into the report yourself to explore.

Just as there is a freshness to every new sports season, there is a freshness to reviewing the information from the SOHM reports, and evaluating the scope of service is always an exciting moment.

---

Dr. Landis is medical director of Wellspan Hospitalists in York, Pa., and a member of SHM’s Practice Analysis Committee.

I think my team of hospitalists is probably tired of hearing my sports analogies. But as I look at the State of Hospital Medicine 2014 report (SOHM), I cannot help but see relationships to athletics.

When you think about football, you automatically contemplate the scope of a particular team and the context of the upcoming season. What are the strengths of the team—do we emphasize offense or defense or special teams? How about the variety of formations or the scheduling and strength of opponents? How about the depth of our roster—what is the talent level available? How do we compare to other teams?

How in the world does this relate to the SOHM? It gives us a chance to evaluate our own hospital medicine groups (HMGs) in the context of the other HMGs across the country. When I look at scope of services and, particularly, the data from Figure 3.1, I am struck with the breadth of the range of services in which HMGs engage. Certainly, our core identity as hospitalists includes admitting referral patients and unassigned patients, but, as of 2014, nearly 90% of hospitalist groups are also managing and co-managing surgical and medical subspecialty patients. To my eyes, the big change since 2012 is the 20% increase in the number of HMGs medically co-managing medical subspecialty patients.

There are some newcomers to our roster, as well—the palliative care and post-acute care work being done by 15% and 25% of our groups, respectively. Particularly striking is the fact that one quarter of HMGs are involved in post-acute care, follow-up clinics, nursing homes, and the like.

My take on this is that factors such as increased complexity of hospitalized patients with lean length of stay and higher acuity needs at discharge transition are driving the need for a measure of continuity and expertise post discharge that may best be provided by HMGs. The trending of the post-acute care challenges/opportunities will certainly be worth watching—sort of like a rookie player who is having a big impact.

Not surprisingly, nighttime admissions work continues to gain traction. Nearly 60% of HMGs are performing nighttime admissions.

In my regional chapter, we recently heard a presentation on “nocturnists.” An interesting contention that caught my attention was that the nocturnist viewed herself as providing expert clinical care during off-hours—particularly at night—and that she was looking to increase the value and not just “put her finger in the dike,” so to speak, until the cavalry arrived at daybreak. As HMG responsibilities increase during the off-hours, I am thinking that my colleague is right: We are going to have to increase our depth and strength at this particular position so that we might actually become known as the “nighttime experts.” I look for this trend to continue.

Finally, I am drawn to the data on care of patients in the ICU, a number that continues to rise—almost 70% of HMGs now. Meanwhile, procedures have dipped to 33% from 53% in the last report. At first, it seemed a little bit puzzling to me that as involvement in the ICUs seemed to increase, procedures diminished. My anecdotal experience is that most of my procedures occurred on patients who had intensive care requirements. Nonetheless, many hospitalists I have talked to seem to believe that the requirement/expectation of imaging in the performance of more and more invasive procedures—now a standard of care— has increasingly driven procedures to specialized areas of the hospital such as imaging/radiology departments. There may also be a net decrease in the number of procedures performed as more noninvasive diagnostic modalities provide satisfactory information.

 

As hospitalists may become focused on throughput (admissions discharges and transfers), the interruption to perform procedures may decrease the net value of the hospitalist to the institution. It may make sense for others to be doing procedures. Whatever the cause, my guess is these two trends may continue.

Diving deeper into the granularity of the report will lead the reader to discover subtle differences and trends. Academics, pediatric hospitalists, and independent HMGs all have some nuances, not to mention regional variation. You will have to dig into the report yourself to explore.

Just as there is a freshness to every new sports season, there is a freshness to reviewing the information from the SOHM reports, and evaluating the scope of service is always an exciting moment.

---

Dr. Landis is medical director of Wellspan Hospitalists in York, Pa., and a member of SHM’s Practice Analysis Committee.

The Veterans Health Administration (VHA) aggressively reorganized its infrastructure in the mid-1990s, undergoing a dramatic transformation from a stagnant “hospital system” to a model “healthcare system” characterized by patient-centered quality care. Central to these efforts was an enterprise-wide update of its existing health information technology (HIT), known as VistA (Veterans Health Information Systems and Technology Architecture), with the rollout of a graphical user interface familiar to most U.S. trainees, the computerized patient record system (CPRS). Although many U.S. hospitals are struggling to meet the national directive related to electronic health records (EHR), the VA boasts a comprehensive electronic records system that has been utilized across all its major clinical sites and units for over 15 years.

In light of the high price tag usually attached to HIT implementation, cost-conscious readers should be able to appreciate the magnitude of the VHA’s accomplishment in rolling out a CPRS in a cost-neutral fashion. Despite a 75% increase in the overall number of patients treated at the VA from 1996 to 2004 (2.8 million to 4.9 million), the VA witnessed a startling net decrease in cost per patient during the same time period—compare $5,058 spent per patient per year in 1996 to $5,048 per patient in 2004. Even more striking was the measurable impact on quality and efficiency in care delivery, particularly in preventive services and chronic disease management and outcomes. In a separate cost-benefit analysis of the VA’s HIT investment and implementation, a staggering benefit of $3.09 billion was found. It is not surprising that the VHA advanced to the top of the leaderboard compared to other U.S. health systems.

In a recent Medscape Electronic Health Records survey of more than 18,500 physicians in a variety of practice situations between April and June of 2014, VA-CPRS received the highest marks for user satisfaction, outshining other popular systems, including Practice Fusion, Epic Systems, and Amazing Charts. It is no wonder that international observers have praised VistA as “the gold standard in clinical informatics.”

What distinguishes the VA’s EHR from any “off-the-shelf” software available is the continued dynamic partnership that exists between frontline end users and supportive programmers. This relationship has resulted in 26 discreet versions of CPRS customized to enhance the capabilities and meet the local needs of VHA clinicians. Emphasis is placed on end user value-added functionality with the vision to optimize workflow rather than requiring physicians to align their clinical processes to a pre-scripted system.

The VA’s transformation has not ground to a halt. Rather, the successor to CPRS, known as the Health Management Platform (HMP), is already being piloted. Built as a groundbreaking, browser-based tool designed to further modernize patient care, the HMP shifts the focus away from a single-provider, single patient-chart model to a patient-centered team-based approach that better reflects and supports the way healthcare teams actually provide care. VA clinicians will be able to customize their own interface to support their workflow, communicate with other healthcare providers using secure internal instant messaging, and access built-in guideline-driven support tools that can assist clinical decision making.

Veterans will be able to input personal information using mobile devices and have complete access to their patient record, patient-provider communication tools, and consumer-friendly disease management information.

Administrators will have the ability to extract population-based data in real time to provide prompt feedback to frontline clinicians and identify specific gaps in healthcare delivery. The new HMP opens doors for improved interactions with system and developer partners worldwide.

 

Clearly the VA is not content to mimic the advancements of others, but once again is poised to revolutionize the arena of healthcare informatics.

---

Dr. Hazelrigg is section chief of hospital medicine at McGuire VAMC in Richmond, VA.  Dr. Kwan is a hospitalist at the VA in San Diego, CA. Both are members of SHM's VA Task Force.

The Veterans Health Administration (VHA) aggressively reorganized its infrastructure in the mid-1990s, undergoing a dramatic transformation from a stagnant “hospital system” to a model “healthcare system” characterized by patient-centered quality care. Central to these efforts was an enterprise-wide update of its existing health information technology (HIT), known as VistA (Veterans Health Information Systems and Technology Architecture), with the rollout of a graphical user interface familiar to most U.S. trainees, the computerized patient record system (CPRS). Although many U.S. hospitals are struggling to meet the national directive related to electronic health records (EHR), the VA boasts a comprehensive electronic records system that has been utilized across all its major clinical sites and units for over 15 years.

In light of the high price tag usually attached to HIT implementation, cost-conscious readers should be able to appreciate the magnitude of the VHA’s accomplishment in rolling out a CPRS in a cost-neutral fashion. Despite a 75% increase in the overall number of patients treated at the VA from 1996 to 2004 (2.8 million to 4.9 million), the VA witnessed a startling net decrease in cost per patient during the same time period—compare $5,058 spent per patient per year in 1996 to $5,048 per patient in 2004. Even more striking was the measurable impact on quality and efficiency in care delivery, particularly in preventive services and chronic disease management and outcomes. In a separate cost-benefit analysis of the VA’s HIT investment and implementation, a staggering benefit of $3.09 billion was found. It is not surprising that the VHA advanced to the top of the leaderboard compared to other U.S. health systems.

In a recent Medscape Electronic Health Records survey of more than 18,500 physicians in a variety of practice situations between April and June of 2014, VA-CPRS received the highest marks for user satisfaction, outshining other popular systems, including Practice Fusion, Epic Systems, and Amazing Charts. It is no wonder that international observers have praised VistA as “the gold standard in clinical informatics.”

What distinguishes the VA’s EHR from any “off-the-shelf” software available is the continued dynamic partnership that exists between frontline end users and supportive programmers. This relationship has resulted in 26 discreet versions of CPRS customized to enhance the capabilities and meet the local needs of VHA clinicians. Emphasis is placed on end user value-added functionality with the vision to optimize workflow rather than requiring physicians to align their clinical processes to a pre-scripted system.

The VA’s transformation has not ground to a halt. Rather, the successor to CPRS, known as the Health Management Platform (HMP), is already being piloted. Built as a groundbreaking, browser-based tool designed to further modernize patient care, the HMP shifts the focus away from a single-provider, single patient-chart model to a patient-centered team-based approach that better reflects and supports the way healthcare teams actually provide care. VA clinicians will be able to customize their own interface to support their workflow, communicate with other healthcare providers using secure internal instant messaging, and access built-in guideline-driven support tools that can assist clinical decision making.

Veterans will be able to input personal information using mobile devices and have complete access to their patient record, patient-provider communication tools, and consumer-friendly disease management information.

Administrators will have the ability to extract population-based data in real time to provide prompt feedback to frontline clinicians and identify specific gaps in healthcare delivery. The new HMP opens doors for improved interactions with system and developer partners worldwide.

 

Clearly the VA is not content to mimic the advancements of others, but once again is poised to revolutionize the arena of healthcare informatics.

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Dr. Hazelrigg is section chief of hospital medicine at McGuire VAMC in Richmond, VA.  Dr. Kwan is a hospitalist at the VA in San Diego, CA. Both are members of SHM's VA Task Force.

The Veterans Health Administration (VHA) aggressively reorganized its infrastructure in the mid-1990s, undergoing a dramatic transformation from a stagnant “hospital system” to a model “healthcare system” characterized by patient-centered quality care. Central to these efforts was an enterprise-wide update of its existing health information technology (HIT), known as VistA (Veterans Health Information Systems and Technology Architecture), with the rollout of a graphical user interface familiar to most U.S. trainees, the computerized patient record system (CPRS). Although many U.S. hospitals are struggling to meet the national directive related to electronic health records (EHR), the VA boasts a comprehensive electronic records system that has been utilized across all its major clinical sites and units for over 15 years.

In light of the high price tag usually attached to HIT implementation, cost-conscious readers should be able to appreciate the magnitude of the VHA’s accomplishment in rolling out a CPRS in a cost-neutral fashion. Despite a 75% increase in the overall number of patients treated at the VA from 1996 to 2004 (2.8 million to 4.9 million), the VA witnessed a startling net decrease in cost per patient during the same time period—compare $5,058 spent per patient per year in 1996 to $5,048 per patient in 2004. Even more striking was the measurable impact on quality and efficiency in care delivery, particularly in preventive services and chronic disease management and outcomes. In a separate cost-benefit analysis of the VA’s HIT investment and implementation, a staggering benefit of $3.09 billion was found. It is not surprising that the VHA advanced to the top of the leaderboard compared to other U.S. health systems.

In a recent Medscape Electronic Health Records survey of more than 18,500 physicians in a variety of practice situations between April and June of 2014, VA-CPRS received the highest marks for user satisfaction, outshining other popular systems, including Practice Fusion, Epic Systems, and Amazing Charts. It is no wonder that international observers have praised VistA as “the gold standard in clinical informatics.”

What distinguishes the VA’s EHR from any “off-the-shelf” software available is the continued dynamic partnership that exists between frontline end users and supportive programmers. This relationship has resulted in 26 discreet versions of CPRS customized to enhance the capabilities and meet the local needs of VHA clinicians. Emphasis is placed on end user value-added functionality with the vision to optimize workflow rather than requiring physicians to align their clinical processes to a pre-scripted system.

The VA’s transformation has not ground to a halt. Rather, the successor to CPRS, known as the Health Management Platform (HMP), is already being piloted. Built as a groundbreaking, browser-based tool designed to further modernize patient care, the HMP shifts the focus away from a single-provider, single patient-chart model to a patient-centered team-based approach that better reflects and supports the way healthcare teams actually provide care. VA clinicians will be able to customize their own interface to support their workflow, communicate with other healthcare providers using secure internal instant messaging, and access built-in guideline-driven support tools that can assist clinical decision making.

Veterans will be able to input personal information using mobile devices and have complete access to their patient record, patient-provider communication tools, and consumer-friendly disease management information.

Administrators will have the ability to extract population-based data in real time to provide prompt feedback to frontline clinicians and identify specific gaps in healthcare delivery. The new HMP opens doors for improved interactions with system and developer partners worldwide.

 

Clearly the VA is not content to mimic the advancements of others, but once again is poised to revolutionize the arena of healthcare informatics.

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Dr. Hazelrigg is section chief of hospital medicine at McGuire VAMC in Richmond, VA.  Dr. Kwan is a hospitalist at the VA in San Diego, CA. Both are members of SHM's VA Task Force.

December 17

Masters Deadline for Nominations

Do you know someone who has earned a place in the “Hall of Fame” for hospital medicine? Nominations for the Master in Hospital Medicine are due next month.

December 31

Membership Ambassadors

Now through Dec. 31, all active SHM members can earn 2015-2016 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members.

January 9, 2015

SFHM and FHM Deadline for Submission

Don’t wait until the last minute to submit your application for the Fellow or Senior Fellow in Hospital Medicine designation. Start now and submit ahead of time.

May 7-9, 2015

Quality and Safety Educators Academy

Quality improvement and patient safety are no longer just electives for trainees; they are part of the core education. That’s why educators everywhere need to learn from SHM’s Quality and Safety Educators Academy.

December 17

Masters Deadline for Nominations

Do you know someone who has earned a place in the “Hall of Fame” for hospital medicine? Nominations for the Master in Hospital Medicine are due next month.

December 31

Membership Ambassadors

Now through Dec. 31, all active SHM members can earn 2015-2016 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members.

January 9, 2015

SFHM and FHM Deadline for Submission

Don’t wait until the last minute to submit your application for the Fellow or Senior Fellow in Hospital Medicine designation. Start now and submit ahead of time.

May 7-9, 2015

Quality and Safety Educators Academy

Quality improvement and patient safety are no longer just electives for trainees; they are part of the core education. That’s why educators everywhere need to learn from SHM’s Quality and Safety Educators Academy.

December 17

Masters Deadline for Nominations

Do you know someone who has earned a place in the “Hall of Fame” for hospital medicine? Nominations for the Master in Hospital Medicine are due next month.

December 31

Membership Ambassadors

Now through Dec. 31, all active SHM members can earn 2015-2016 dues credits and special recognition for recruiting new physician, physician assistant, nurse practitioner, pharmacist, or affiliate members.

January 9, 2015

SFHM and FHM Deadline for Submission

Don’t wait until the last minute to submit your application for the Fellow or Senior Fellow in Hospital Medicine designation. Start now and submit ahead of time.

May 7-9, 2015

Quality and Safety Educators Academy

Quality improvement and patient safety are no longer just electives for trainees; they are part of the core education. That’s why educators everywhere need to learn from SHM’s Quality and Safety Educators Academy.

Adverse drug events and medication errors are unfortunately all too common within hospitals, but hospitalists can now take the lead in preventing them using SHM’s MARQUIS [Multi-Center Medication Reconciliation Quality Improvement Study] toolkit.

The authors of the new toolkit outline the hospitalist’s role in reducing medication errors as:

• Take responsibility for the accuracy of the medication reconciliation process for each patient under your care;
• Lead, coordinate, or participate in medication reconciliation quality improvement (QI) efforts with other key team members on the “front lines” to inform the hospital QI team on key interventions that would lead to improved patient outcomes;
• Become trained in taking the “best possible medication history” and in using effective discharge medication counseling; and
• Identify patients who are at high risk for a medication reconciliation error and would benefit from a more intensive medication reconciliation process.

“The MARQUIS study is important because it shows the potential of a mentored implementation effort, working with local hospitalist leaders and a QI toolkit, to improve medication safety related to the medication reconciliation process,” says MARQUIS principal investigator Jeff Schnipper, MD, MPH, FHM.

“It also shows the importance of institutional commitment to the success of these efforts. Lastly, hospitalists need to realize that medication reconciliation is not just some external regulatory requirement—it’s about the safety of the medications they order—and, therefore, that they need to ensure the quality of the process for the patients they care for and to lead efforts to improve the process across their hospitals.”

For more information, visit www.hospitalmedicine.org/marquis.

Adverse drug events and medication errors are unfortunately all too common within hospitals, but hospitalists can now take the lead in preventing them using SHM’s MARQUIS [Multi-Center Medication Reconciliation Quality Improvement Study] toolkit.

The authors of the new toolkit outline the hospitalist’s role in reducing medication errors as:

• Take responsibility for the accuracy of the medication reconciliation process for each patient under your care;
• Lead, coordinate, or participate in medication reconciliation quality improvement (QI) efforts with other key team members on the “front lines” to inform the hospital QI team on key interventions that would lead to improved patient outcomes;
• Become trained in taking the “best possible medication history” and in using effective discharge medication counseling; and
• Identify patients who are at high risk for a medication reconciliation error and would benefit from a more intensive medication reconciliation process.

“The MARQUIS study is important because it shows the potential of a mentored implementation effort, working with local hospitalist leaders and a QI toolkit, to improve medication safety related to the medication reconciliation process,” says MARQUIS principal investigator Jeff Schnipper, MD, MPH, FHM.

“It also shows the importance of institutional commitment to the success of these efforts. Lastly, hospitalists need to realize that medication reconciliation is not just some external regulatory requirement—it’s about the safety of the medications they order—and, therefore, that they need to ensure the quality of the process for the patients they care for and to lead efforts to improve the process across their hospitals.”

For more information, visit www.hospitalmedicine.org/marquis.

Adverse drug events and medication errors are unfortunately all too common within hospitals, but hospitalists can now take the lead in preventing them using SHM’s MARQUIS [Multi-Center Medication Reconciliation Quality Improvement Study] toolkit.

The authors of the new toolkit outline the hospitalist’s role in reducing medication errors as:

• Take responsibility for the accuracy of the medication reconciliation process for each patient under your care;
• Lead, coordinate, or participate in medication reconciliation quality improvement (QI) efforts with other key team members on the “front lines” to inform the hospital QI team on key interventions that would lead to improved patient outcomes;
• Become trained in taking the “best possible medication history” and in using effective discharge medication counseling; and
• Identify patients who are at high risk for a medication reconciliation error and would benefit from a more intensive medication reconciliation process.

“The MARQUIS study is important because it shows the potential of a mentored implementation effort, working with local hospitalist leaders and a QI toolkit, to improve medication safety related to the medication reconciliation process,” says MARQUIS principal investigator Jeff Schnipper, MD, MPH, FHM.

“It also shows the importance of institutional commitment to the success of these efforts. Lastly, hospitalists need to realize that medication reconciliation is not just some external regulatory requirement—it’s about the safety of the medications they order—and, therefore, that they need to ensure the quality of the process for the patients they care for and to lead efforts to improve the process across their hospitals.”

For more information, visit www.hospitalmedicine.org/marquis.