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Many Older Acute MI Patients Don't Complete Rehab
(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.
Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.
Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.
"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."
Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.
The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.
Of those who had not been referred, 1,795 attended at least one session.
Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.
Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.
Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.
"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.
Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.
Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.
"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.
Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.
Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.
"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."
(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.
Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.
Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.
"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."
Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.
The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.
Of those who had not been referred, 1,795 attended at least one session.
Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.
Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.
Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.
"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.
Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.
Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.
"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.
Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.
Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.
"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."
(Reuters Health) - Most older adults who are hospitalized for acute myocardial infarction do not attend even one of the recommended cardiac rehabilitation sessions, according to a new study.
Cardiac rehab increases physical and cardiovascular fitness through structured exercise and education sessions, said lead author Dr. Jacob A. Doll, of Duke Clinical Research Institute in Durham, North Carolina.
Patients may attend individual or group sessions to improve medication adherence, help them quit smoking, lose weight, improve their diet and manage chronic diseases, while also focusing on psychological and social wellbeing, he said.
"Some people will be too sick after a heart attack to exercise safely, but this should be a fairly low percentage," Doll told Reuters Health by email. "Most other people can benefit, especially older adults."
Researchers used data on 58,269 patients 65 years or older who had acute MI between 2007 and 2010.
The researchers found that 36,376 patients, or 62%, were referred to cardiac rehab - but only 11,862 attended at least one rehab session over the year following hospital discharge.
Of those who had not been referred, 1,795 attended at least one session.
Half of those who went to the rehab program attended less than 26 sessions, though insurance usually covers 36 sessions - or two to three sessions per week, as reported August 3 in JAMA Internal Medicine.
Less than a quarter of the total group of MI patients attended at least one rehab session, and only 5% completed 36 sessions.
Younger white male nonsmokers with few other health problems were most likely to attend cardiac rehab.
"Not all (heart attack) patients are referred, some for valid reasons such as inability to exercise, difficulty in scheduling due to their job, lack of transportation, need to care for a sick spouse, etc," said Dr. Jerome L. Fleg of the National Heart, Lung and Blood Institute in Bethesda, Maryland.
Rehab sessions typically involve five to 10 minutes of warm-up, 30 to 40 minutes of walking, stationary cycling, or elliptical machine exercise, followed by five to 10 minutes of cool down, said Fleg, who was not part of the new study.
Hospitals should improve referral rates, and should encourage enrolled patients to actually complete the rehab programs, Doll said.
"Many people might feel that cardiac rehab is not for them, potentially because they feel they are not able to exercise or are too sick," he said.
Medicare recipients, like those in this study, generally have all costs covered for cardiac rehab, Fleg told Reuters Health by email.
Most other insurances cover cardiac rehab, but copayments may be cost-prohibitive for some people, and those living in rural areas may have to drive long distances to find a center, Doll said.
"Health systems and insurers should consider reducing copayments in order to improve access, since cardiac rehabilitation has been shown (to) improve survival and functioning after a heart attack," he said. "For people that cannot attend a traditional program, we may need new ways to deliver rehab services, such as home-based programs."
CMS releases ICD-10-CM valid codes and code titles
The Centers for Medicare & Medicaid Services has released a complete list of the 2016 ICD-10-CM valid codes and code titles in a downloadable file.
The file can be used by physicians and their staffs to make sure “they are reporting all characters in a valid ICD-10-CM code,” CMS officials said.
“This list should assist providers who are unsure if additional characters are needed, such as the addition of a 7th character in order to arrive at a valid code.”
The file is available for download on the 2016 ICD-10-CM and GEMs website. It also features the 2016 ICD-10-PCS valid codes and code titles.
The Centers for Medicare & Medicaid Services has released a complete list of the 2016 ICD-10-CM valid codes and code titles in a downloadable file.
The file can be used by physicians and their staffs to make sure “they are reporting all characters in a valid ICD-10-CM code,” CMS officials said.
“This list should assist providers who are unsure if additional characters are needed, such as the addition of a 7th character in order to arrive at a valid code.”
The file is available for download on the 2016 ICD-10-CM and GEMs website. It also features the 2016 ICD-10-PCS valid codes and code titles.
The Centers for Medicare & Medicaid Services has released a complete list of the 2016 ICD-10-CM valid codes and code titles in a downloadable file.
The file can be used by physicians and their staffs to make sure “they are reporting all characters in a valid ICD-10-CM code,” CMS officials said.
“This list should assist providers who are unsure if additional characters are needed, such as the addition of a 7th character in order to arrive at a valid code.”
The file is available for download on the 2016 ICD-10-CM and GEMs website. It also features the 2016 ICD-10-PCS valid codes and code titles.
Listen Now: HM15 RIV Poster Presenters Discuss Research Projects
Two hospitalists who presented RIV posters at HM15 talk about their projects. Dr. Brian Poustinchian worked on a bedside rounding study at Midwestern University in Illinois, and Dr. Jennifer Pascoe worked on a poster about patients leaving the hospital against medical advice, focusing on a case of her own at the University of Rochester.
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/08/Tales-from-the-RIV.mp3"][/audio]
Two hospitalists who presented RIV posters at HM15 talk about their projects. Dr. Brian Poustinchian worked on a bedside rounding study at Midwestern University in Illinois, and Dr. Jennifer Pascoe worked on a poster about patients leaving the hospital against medical advice, focusing on a case of her own at the University of Rochester.
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/08/Tales-from-the-RIV.mp3"][/audio]
Two hospitalists who presented RIV posters at HM15 talk about their projects. Dr. Brian Poustinchian worked on a bedside rounding study at Midwestern University in Illinois, and Dr. Jennifer Pascoe worked on a poster about patients leaving the hospital against medical advice, focusing on a case of her own at the University of Rochester.
[audio mp3="http://www.the-hospitalist.org/wp-content/uploads/2015/08/Tales-from-the-RIV.mp3"][/audio]
PHM15: Writing and Publishing Quality Improvement (QI)
Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.
Session analysis:
QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.
Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:
- A specific goal/aim statement needs to be identified,
- The measurement needs to match your goal/aim,
- Always start with writing your methods since you know exactly what you did,
- Plot data over time using a run chart, and
- Keep a notebook with documentation of dates all interventions started.
It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.
Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.
Session analysis:
QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.
Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:
- A specific goal/aim statement needs to be identified,
- The measurement needs to match your goal/aim,
- Always start with writing your methods since you know exactly what you did,
- Plot data over time using a run chart, and
- Keep a notebook with documentation of dates all interventions started.
It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.
Presenters: Dr. Patrick Brady, Dr. Michele Saysana, Dr. Christine White, and Dr. Mark Shen.
Session analysis:
QI is about making positive changes in the delivery of healthcare. Multiple QI interventions are been implemented daily throughout our hospitals. Some of those interventions result in positive changes and affect specific outcomes the way we want. It is our job, as hospitalists, to share them with our colleagues so patients can benefit from them.
Some of the barriers to publishing QI as identified by the group are: lack of time, resources available and administrative support, lack of mentorship, and unrecognized value of QI in the academic world. The group also identified some strategies to be successful at writing and publishing QI, including: blocking time in the schedule and labeling it "writing days," joining a collaborative, reaching out to Journal editors and becoming familiar with the SQUIRE guidelines. Some key points as discussed by the experts that will aid during the process of writing QI are:
- A specific goal/aim statement needs to be identified,
- The measurement needs to match your goal/aim,
- Always start with writing your methods since you know exactly what you did,
- Plot data over time using a run chart, and
- Keep a notebook with documentation of dates all interventions started.
It is also important for everyone to know there are multiple quality and safety journals willing to review QI manuscripts for publication.
Whispered pectoriloquy
The other day, I had to look up “whispered pectoriloquy” to be reminded of what it meant. The last time I had seen the term was when I was a third-year medical student.
I was motivated to look it up now as I was reading the review of systems in a patient note generated from an electronic health record. Interestingly, the note was written by a consulting urologist.
I have become accustomed to only glancing at the review of systems in most of the medical letters I receive, but this particular review of systems caught my attention. As I looked carefully at it, I noticed that the urologist documented that the patient denied chest pain, shortness of breath, double vision, and – oddly – loose stools. In fairness, the note also documented that the patient denied blood in his urine and nocturia.
I was quite doubtful that the physician actually asked the patient about chest pain and double vision, so I was facing a dilemma: believe all of the note, none of the note, or just the parts I felt confident were actually asked.
For a long time, I really did not think much about the problem. I just processed the observation with a sense of mild amusement and absurdity, and mostly with an acceptance that these kinds of observations were an annoying but unavoidable side effect of systems created by computer engineers and forced upon doctors.
But I became more concerned as I read further. The physical exam documented a detailed cardiac exam with no murmurs, rubs, or gallops, and the pulmonary exam showed no wheezing or whispered pectoriloquy. These documentation inaccuracies, while amusing, truly are a source of potential liability and ultimately detract from our ability to find the important information contained within a note.
Fundamentally, medical notes are written to document what occurred during a patient visit. They should allow the physician to recall what happened at the visit, whether the patient follows up in a day, a week, or 3 years later. They also need to communicate the details of the visit to any other clinician who may see the patient at some point in the future.
In recent decades, notes also have become the sole evidence required to justify physician charges. To bill at a certain rate, a physician must document a minimum amount of information, including a specific number of elements in the review of systems and the physical exam. Recognizing that compliance with billing requirements is an important goal of clinicians, many EHRs have made it too easy to “bloat” a note by including reams of irrelevant information – thereby making it difficult to find the important information the note was intended to communicate in the first place.
Notes from some EHRs remind us of the Wendy’s commercial from the 1980s: They force us to ask, “Where’s the beef?”
This is because many EHR implementations rely on default settings. These maximize documentation for billing but unfortunately leave the “beef” (in our case, the real information relevant to patient care) buried in lines of irrelevant, specious, and sometimes downright fictitious information.
We can do better. Virtually every EHR currently in use allows clinicians to customize fields so that notes can be easily written to reflect the realities of our differing practices.
Put more simply, you really can (and should) have a review of systems that is relevant to what you do.
If you always ask about chest pain, difficulty breathing, and abdominal pain, you can include negative responses to those questions with one click and then add in any positive aspects the patient may report. If you are seeing a patient with asthma and you generally ask the same questions – exacerbations in the last month, frequency of the use of albuterol, nighttime awakenings, symptoms with exercise, etc. – most EHR systems will allow you to set up the record to populate an asthma review of systems that includes defined responses you can individualize for each patient.
Electronic documentation of the physical exam also should reflect the examination that you routinely do by default. Then you can make simple changes to adapt your personalized predefined settings and correctly reflect what occurred with each patient.
For that same asthma patient, the physical exam should give the details of the heart and lung exam but should not include any mention of an abdominal exam unless one was actually done. A current high-quality EHR also should populate the appropriate physical exam areas with one click of a button.
It has been more than 3 years since the majority of practices transitioned to electronic health records, but we still see far too many clinicians struggling with systems and describing data that reflect things they have not done, all due to the use of default settings that have never been changed. It is important to understand how to customize your EHR to meet your needs and to make the individual efforts required to learn how to effectively use the current instruments of our craft.
As for whispered pectoriloquy, it is the increased loudness of a whispered word heard on auscultation over an area of lung consolidation. It is similar to tactile fremitus, where consolidation is noted by the vibratory feel in your hand placed on the chest of a patient. It should be a very rare event in our day and age that any description of whispered pectoriloquy should sneak its way into our record, particularly for a urology visit.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
The other day, I had to look up “whispered pectoriloquy” to be reminded of what it meant. The last time I had seen the term was when I was a third-year medical student.
I was motivated to look it up now as I was reading the review of systems in a patient note generated from an electronic health record. Interestingly, the note was written by a consulting urologist.
I have become accustomed to only glancing at the review of systems in most of the medical letters I receive, but this particular review of systems caught my attention. As I looked carefully at it, I noticed that the urologist documented that the patient denied chest pain, shortness of breath, double vision, and – oddly – loose stools. In fairness, the note also documented that the patient denied blood in his urine and nocturia.
I was quite doubtful that the physician actually asked the patient about chest pain and double vision, so I was facing a dilemma: believe all of the note, none of the note, or just the parts I felt confident were actually asked.
For a long time, I really did not think much about the problem. I just processed the observation with a sense of mild amusement and absurdity, and mostly with an acceptance that these kinds of observations were an annoying but unavoidable side effect of systems created by computer engineers and forced upon doctors.
But I became more concerned as I read further. The physical exam documented a detailed cardiac exam with no murmurs, rubs, or gallops, and the pulmonary exam showed no wheezing or whispered pectoriloquy. These documentation inaccuracies, while amusing, truly are a source of potential liability and ultimately detract from our ability to find the important information contained within a note.
Fundamentally, medical notes are written to document what occurred during a patient visit. They should allow the physician to recall what happened at the visit, whether the patient follows up in a day, a week, or 3 years later. They also need to communicate the details of the visit to any other clinician who may see the patient at some point in the future.
In recent decades, notes also have become the sole evidence required to justify physician charges. To bill at a certain rate, a physician must document a minimum amount of information, including a specific number of elements in the review of systems and the physical exam. Recognizing that compliance with billing requirements is an important goal of clinicians, many EHRs have made it too easy to “bloat” a note by including reams of irrelevant information – thereby making it difficult to find the important information the note was intended to communicate in the first place.
Notes from some EHRs remind us of the Wendy’s commercial from the 1980s: They force us to ask, “Where’s the beef?”
This is because many EHR implementations rely on default settings. These maximize documentation for billing but unfortunately leave the “beef” (in our case, the real information relevant to patient care) buried in lines of irrelevant, specious, and sometimes downright fictitious information.
We can do better. Virtually every EHR currently in use allows clinicians to customize fields so that notes can be easily written to reflect the realities of our differing practices.
Put more simply, you really can (and should) have a review of systems that is relevant to what you do.
If you always ask about chest pain, difficulty breathing, and abdominal pain, you can include negative responses to those questions with one click and then add in any positive aspects the patient may report. If you are seeing a patient with asthma and you generally ask the same questions – exacerbations in the last month, frequency of the use of albuterol, nighttime awakenings, symptoms with exercise, etc. – most EHR systems will allow you to set up the record to populate an asthma review of systems that includes defined responses you can individualize for each patient.
Electronic documentation of the physical exam also should reflect the examination that you routinely do by default. Then you can make simple changes to adapt your personalized predefined settings and correctly reflect what occurred with each patient.
For that same asthma patient, the physical exam should give the details of the heart and lung exam but should not include any mention of an abdominal exam unless one was actually done. A current high-quality EHR also should populate the appropriate physical exam areas with one click of a button.
It has been more than 3 years since the majority of practices transitioned to electronic health records, but we still see far too many clinicians struggling with systems and describing data that reflect things they have not done, all due to the use of default settings that have never been changed. It is important to understand how to customize your EHR to meet your needs and to make the individual efforts required to learn how to effectively use the current instruments of our craft.
As for whispered pectoriloquy, it is the increased loudness of a whispered word heard on auscultation over an area of lung consolidation. It is similar to tactile fremitus, where consolidation is noted by the vibratory feel in your hand placed on the chest of a patient. It should be a very rare event in our day and age that any description of whispered pectoriloquy should sneak its way into our record, particularly for a urology visit.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
The other day, I had to look up “whispered pectoriloquy” to be reminded of what it meant. The last time I had seen the term was when I was a third-year medical student.
I was motivated to look it up now as I was reading the review of systems in a patient note generated from an electronic health record. Interestingly, the note was written by a consulting urologist.
I have become accustomed to only glancing at the review of systems in most of the medical letters I receive, but this particular review of systems caught my attention. As I looked carefully at it, I noticed that the urologist documented that the patient denied chest pain, shortness of breath, double vision, and – oddly – loose stools. In fairness, the note also documented that the patient denied blood in his urine and nocturia.
I was quite doubtful that the physician actually asked the patient about chest pain and double vision, so I was facing a dilemma: believe all of the note, none of the note, or just the parts I felt confident were actually asked.
For a long time, I really did not think much about the problem. I just processed the observation with a sense of mild amusement and absurdity, and mostly with an acceptance that these kinds of observations were an annoying but unavoidable side effect of systems created by computer engineers and forced upon doctors.
But I became more concerned as I read further. The physical exam documented a detailed cardiac exam with no murmurs, rubs, or gallops, and the pulmonary exam showed no wheezing or whispered pectoriloquy. These documentation inaccuracies, while amusing, truly are a source of potential liability and ultimately detract from our ability to find the important information contained within a note.
Fundamentally, medical notes are written to document what occurred during a patient visit. They should allow the physician to recall what happened at the visit, whether the patient follows up in a day, a week, or 3 years later. They also need to communicate the details of the visit to any other clinician who may see the patient at some point in the future.
In recent decades, notes also have become the sole evidence required to justify physician charges. To bill at a certain rate, a physician must document a minimum amount of information, including a specific number of elements in the review of systems and the physical exam. Recognizing that compliance with billing requirements is an important goal of clinicians, many EHRs have made it too easy to “bloat” a note by including reams of irrelevant information – thereby making it difficult to find the important information the note was intended to communicate in the first place.
Notes from some EHRs remind us of the Wendy’s commercial from the 1980s: They force us to ask, “Where’s the beef?”
This is because many EHR implementations rely on default settings. These maximize documentation for billing but unfortunately leave the “beef” (in our case, the real information relevant to patient care) buried in lines of irrelevant, specious, and sometimes downright fictitious information.
We can do better. Virtually every EHR currently in use allows clinicians to customize fields so that notes can be easily written to reflect the realities of our differing practices.
Put more simply, you really can (and should) have a review of systems that is relevant to what you do.
If you always ask about chest pain, difficulty breathing, and abdominal pain, you can include negative responses to those questions with one click and then add in any positive aspects the patient may report. If you are seeing a patient with asthma and you generally ask the same questions – exacerbations in the last month, frequency of the use of albuterol, nighttime awakenings, symptoms with exercise, etc. – most EHR systems will allow you to set up the record to populate an asthma review of systems that includes defined responses you can individualize for each patient.
Electronic documentation of the physical exam also should reflect the examination that you routinely do by default. Then you can make simple changes to adapt your personalized predefined settings and correctly reflect what occurred with each patient.
For that same asthma patient, the physical exam should give the details of the heart and lung exam but should not include any mention of an abdominal exam unless one was actually done. A current high-quality EHR also should populate the appropriate physical exam areas with one click of a button.
It has been more than 3 years since the majority of practices transitioned to electronic health records, but we still see far too many clinicians struggling with systems and describing data that reflect things they have not done, all due to the use of default settings that have never been changed. It is important to understand how to customize your EHR to meet your needs and to make the individual efforts required to learn how to effectively use the current instruments of our craft.
As for whispered pectoriloquy, it is the increased loudness of a whispered word heard on auscultation over an area of lung consolidation. It is similar to tactile fremitus, where consolidation is noted by the vibratory feel in your hand placed on the chest of a patient. It should be a very rare event in our day and age that any description of whispered pectoriloquy should sneak its way into our record, particularly for a urology visit.
Dr. Notte is a family physician and clinical informaticist for Abington (Pa.) Memorial Hospital. He is a partner in EHR Practice Consultants, a firm that aids physicians in adopting electronic health records. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.
TeamHealth Announces $1.6 Billion Acquisition of IPC Healthcare
Coding mistakes lead to $35 million in drug overpayments
Coding mistakes made on behalf of physicians and other health providers led to more than $35 million in Medicare overpayments for outpatient drugs, a government watchdog has found.
An audit by the U.S. Department of Health & Human Services Office of Inspector General (OIG) discovered that Medicare contractors in 13 jurisdictions overpaid Medicare Part B providers by $35.8 million between July 2009 and June 2012. Erroneous codes and incorrect units of service submitted on behalf of those providers were the top reasons for the overpayments, according to the OIG report, released July 29.
Incorrect units of service resulted in net overpayments of $26 million, according to the report. One provider, for instance, administered 6 units of rituximab to a patient and billed for 60 units. The same provider made this type of error on 21 separate occasions leading Medicare contractors to pay $811,562 when they should have paid $67,863. The medications most frequently overpaid because of incorrect units of service were: adenosine, rituximab, infliximab, leuprolide acetate, and bortezomib.
Other common billing mistakes by physicians that resulted in overpayments included, insufficient documentation about patient services, billing for outpatient drugs in which payment was already included in that of a primary procedure, incorrect use of Healthcare Common Procedure Coding System (HCPCS) codes, and billing Medicare for noncovered outpatient drugs.
As of May 4, the Centers for Medicare & Medicaid Services had recovered 63% of the overpayments found in the OIG audit, according to the report. However, the OIG also identified potential overpayments for outpatient drugs that were billed after its audit period. Specifically, officials said Medicare contractors could recover as much as $11.5 million in overpayments if they review outpatient drug payments billed from July 2012 through June 2014.
The OIG recommended that CMS collect the remaining overpayments, conduct reviews on the time period after the initial audit period, continue to educate providers on correct billing of outpatient drugs, and continue to implement line item and date-of-service Medically Unlikely Edits for additional outpatient drugs.
On Twitter @legal_med
Coding mistakes made on behalf of physicians and other health providers led to more than $35 million in Medicare overpayments for outpatient drugs, a government watchdog has found.
An audit by the U.S. Department of Health & Human Services Office of Inspector General (OIG) discovered that Medicare contractors in 13 jurisdictions overpaid Medicare Part B providers by $35.8 million between July 2009 and June 2012. Erroneous codes and incorrect units of service submitted on behalf of those providers were the top reasons for the overpayments, according to the OIG report, released July 29.
Incorrect units of service resulted in net overpayments of $26 million, according to the report. One provider, for instance, administered 6 units of rituximab to a patient and billed for 60 units. The same provider made this type of error on 21 separate occasions leading Medicare contractors to pay $811,562 when they should have paid $67,863. The medications most frequently overpaid because of incorrect units of service were: adenosine, rituximab, infliximab, leuprolide acetate, and bortezomib.
Other common billing mistakes by physicians that resulted in overpayments included, insufficient documentation about patient services, billing for outpatient drugs in which payment was already included in that of a primary procedure, incorrect use of Healthcare Common Procedure Coding System (HCPCS) codes, and billing Medicare for noncovered outpatient drugs.
As of May 4, the Centers for Medicare & Medicaid Services had recovered 63% of the overpayments found in the OIG audit, according to the report. However, the OIG also identified potential overpayments for outpatient drugs that were billed after its audit period. Specifically, officials said Medicare contractors could recover as much as $11.5 million in overpayments if they review outpatient drug payments billed from July 2012 through June 2014.
The OIG recommended that CMS collect the remaining overpayments, conduct reviews on the time period after the initial audit period, continue to educate providers on correct billing of outpatient drugs, and continue to implement line item and date-of-service Medically Unlikely Edits for additional outpatient drugs.
On Twitter @legal_med
Coding mistakes made on behalf of physicians and other health providers led to more than $35 million in Medicare overpayments for outpatient drugs, a government watchdog has found.
An audit by the U.S. Department of Health & Human Services Office of Inspector General (OIG) discovered that Medicare contractors in 13 jurisdictions overpaid Medicare Part B providers by $35.8 million between July 2009 and June 2012. Erroneous codes and incorrect units of service submitted on behalf of those providers were the top reasons for the overpayments, according to the OIG report, released July 29.
Incorrect units of service resulted in net overpayments of $26 million, according to the report. One provider, for instance, administered 6 units of rituximab to a patient and billed for 60 units. The same provider made this type of error on 21 separate occasions leading Medicare contractors to pay $811,562 when they should have paid $67,863. The medications most frequently overpaid because of incorrect units of service were: adenosine, rituximab, infliximab, leuprolide acetate, and bortezomib.
Other common billing mistakes by physicians that resulted in overpayments included, insufficient documentation about patient services, billing for outpatient drugs in which payment was already included in that of a primary procedure, incorrect use of Healthcare Common Procedure Coding System (HCPCS) codes, and billing Medicare for noncovered outpatient drugs.
As of May 4, the Centers for Medicare & Medicaid Services had recovered 63% of the overpayments found in the OIG audit, according to the report. However, the OIG also identified potential overpayments for outpatient drugs that were billed after its audit period. Specifically, officials said Medicare contractors could recover as much as $11.5 million in overpayments if they review outpatient drug payments billed from July 2012 through June 2014.
The OIG recommended that CMS collect the remaining overpayments, conduct reviews on the time period after the initial audit period, continue to educate providers on correct billing of outpatient drugs, and continue to implement line item and date-of-service Medically Unlikely Edits for additional outpatient drugs.
On Twitter @legal_med
PHM15: Urinary Tract Infection (UTI) Management in Febrile Infants
Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?
The current evidence (applying to 2 month-2 years) in a nutshell includes:
- Oral and parental antibiotics are equally efficacious,
- Duration of treatment is a wide range of 7-14 days,
- Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
- Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).
Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:
- The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
- The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.
The RIVUR study raised more questions:
- Is there a difference in outcome if a child had concurrent bacteremia?
- There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.
- How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?
- Urinalysis in those infants
- Could inflammatory markers accurately identify infants at high risk for more severe disease?
- Not really.
Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.
Key Takeaways:
- The guidelines represent a living and dynamic tool that integrates the best evidence we have.
- There is new research evolving and lessons to be learned.
Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.
Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?
The current evidence (applying to 2 month-2 years) in a nutshell includes:
- Oral and parental antibiotics are equally efficacious,
- Duration of treatment is a wide range of 7-14 days,
- Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
- Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).
Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:
- The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
- The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.
The RIVUR study raised more questions:
- Is there a difference in outcome if a child had concurrent bacteremia?
- There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.
- How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?
- Urinalysis in those infants
- Could inflammatory markers accurately identify infants at high risk for more severe disease?
- Not really.
Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.
Key Takeaways:
- The guidelines represent a living and dynamic tool that integrates the best evidence we have.
- There is new research evolving and lessons to be learned.
Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.
Drs. Pate and Engel presented a hot topic in pediatric hospital medicine, sparking fruitful conversation about current evidence, identified gaps, and controversies regarding the management of febrile infants with urinary tract infections. After the American Academy of Pediatrics published the updated clinical guideline in 2011, controversies about radioimaging, duration of treatment, and pursuit of laboratory evaluations arose. These controversies continue today, and value and gold standard tests are now being questioned. Should urine culture truly be the gold standard to define a UTI?
The current evidence (applying to 2 month-2 years) in a nutshell includes:
- Oral and parental antibiotics are equally efficacious,
- Duration of treatment is a wide range of 7-14 days,
- Positive UA indicating inflammation/infection and a culture >50,000 uropathogens/ml is needed to make the diagnosis, and
- Febrile infants with first UTI should get a renal ultrasound; only if the ultrasound is abnormal should patients get a Voiding Cystourethrogram (VCUG).
Since the guideline was published in 2011, there has been continued disagreement between pediatricians and pediatric urologists. When thinking about high-value care, what value is added by doing the renal ultrasound and/or VCUG? The research over the last couple of years shows that although there is concern that UTIs lead to renal scarring and chronic kidney disease, in the absence of structural kidney abnormalities, recurrent UTIs cause at most 0.3% of chronic kidney disease. The takehome point from the 2014 RIVUR study is:
- The treatment group had significantly higher rates of resistance organisms (63% ppx 19% placebo).
- The NNT with prophylaxis in children with VUR is 9 children for 2 years to prevent 1 UTI, or 6570 days of antibiotics to prevent one 7-14 day course.
The RIVUR study raised more questions:
- Is there a difference in outcome if a child had concurrent bacteremia?
- There is no significant difference in clinical presentation between an isolated UTI and an infant with bacteremia. Those patients with bacteremia received longer duration of parenteral antibiotics, but the number of days were highly variable and outcomes were excellent overall regardless.
- How accurate is UA in the diagnosis of urinary tract infections in infants less than 3 months of age?
- Urinalysis in those infants
- Could inflammatory markers accurately identify infants at high risk for more severe disease?
- Not really.
Guidelines were reviewed, controversies were discussed, and questions were proposed. The session ended with tools to take home to help change hospital practice, and quality-UTI projects metrics were shared, as this is the next AAP VIP project about to launch.
Key Takeaways:
- The guidelines represent a living and dynamic tool that integrates the best evidence we have.
- There is new research evolving and lessons to be learned.
Dr. Hopkins is an academic pediatric hospitalist and instructor at All Children's Hospital Johns Hopkins Medicine, St. Petersburg, Fla.
New Expectations for Value-Based Healthcare
A new book by three leading hospital medicine advocates for maximizing efficiency and outcomes while managing costs and avoiding waste in healthcare—also known as value-based healthcare—offers a primer filled with practical advice for doctors and other clinicians.1 The hospitalist authors of Understanding Value-Based Healthcare, Christopher Moriates, MD, of the University of California-San Francisco, Vineet Arora, MD, MAPP, of the University of Chicago, and Neel Shah, MD, MPP, of Harvard Medical School, all have leadership positions in Costs of Care, a nonprofit organization formed in 2009 to help empower patients and their caregivers to deflate medical bills.
In a recent op-ed piece at MedPage Today, the book’s authors emphasize the harms for patients when doctors fail to consider the impact of medical bills or screen patients for financial harm.2 Doctors should help their patients navigate tradeoffs of lower-cost treatment options. The authors hope to embed principles of value-based care into the apprenticeship of health professional education through initiatives such as Costs of Care’s “Teaching Value & Choosing Wisely Challenge,” which received 80 submissions from medical students and faculty from across the United States and Canada presenting bright ideas and innovations for integrating value into education.
References
- Moriates C, Arora V, Shah N. Understanding Value-Based Healthcare. New York City: McGraw Hill Education; 2015.
- Moriates C, Arora V, Shah N. Op-ed: how to rein in out-of-control healthcare costs. May 5, 2015. MedPage Today. Accessed July 2, 2015.
A new book by three leading hospital medicine advocates for maximizing efficiency and outcomes while managing costs and avoiding waste in healthcare—also known as value-based healthcare—offers a primer filled with practical advice for doctors and other clinicians.1 The hospitalist authors of Understanding Value-Based Healthcare, Christopher Moriates, MD, of the University of California-San Francisco, Vineet Arora, MD, MAPP, of the University of Chicago, and Neel Shah, MD, MPP, of Harvard Medical School, all have leadership positions in Costs of Care, a nonprofit organization formed in 2009 to help empower patients and their caregivers to deflate medical bills.
In a recent op-ed piece at MedPage Today, the book’s authors emphasize the harms for patients when doctors fail to consider the impact of medical bills or screen patients for financial harm.2 Doctors should help their patients navigate tradeoffs of lower-cost treatment options. The authors hope to embed principles of value-based care into the apprenticeship of health professional education through initiatives such as Costs of Care’s “Teaching Value & Choosing Wisely Challenge,” which received 80 submissions from medical students and faculty from across the United States and Canada presenting bright ideas and innovations for integrating value into education.
References
- Moriates C, Arora V, Shah N. Understanding Value-Based Healthcare. New York City: McGraw Hill Education; 2015.
- Moriates C, Arora V, Shah N. Op-ed: how to rein in out-of-control healthcare costs. May 5, 2015. MedPage Today. Accessed July 2, 2015.
A new book by three leading hospital medicine advocates for maximizing efficiency and outcomes while managing costs and avoiding waste in healthcare—also known as value-based healthcare—offers a primer filled with practical advice for doctors and other clinicians.1 The hospitalist authors of Understanding Value-Based Healthcare, Christopher Moriates, MD, of the University of California-San Francisco, Vineet Arora, MD, MAPP, of the University of Chicago, and Neel Shah, MD, MPP, of Harvard Medical School, all have leadership positions in Costs of Care, a nonprofit organization formed in 2009 to help empower patients and their caregivers to deflate medical bills.
In a recent op-ed piece at MedPage Today, the book’s authors emphasize the harms for patients when doctors fail to consider the impact of medical bills or screen patients for financial harm.2 Doctors should help their patients navigate tradeoffs of lower-cost treatment options. The authors hope to embed principles of value-based care into the apprenticeship of health professional education through initiatives such as Costs of Care’s “Teaching Value & Choosing Wisely Challenge,” which received 80 submissions from medical students and faculty from across the United States and Canada presenting bright ideas and innovations for integrating value into education.
References
- Moriates C, Arora V, Shah N. Understanding Value-Based Healthcare. New York City: McGraw Hill Education; 2015.
- Moriates C, Arora V, Shah N. Op-ed: how to rein in out-of-control healthcare costs. May 5, 2015. MedPage Today. Accessed July 2, 2015.
Tips for Hospitalists on Spending More of Their Time at the Top of Their License
Hospitalists spend too little time working at the top of their license. Put differently, I think a hospitalist often spends only about 1.5 to two hours in a 10- or 12-hour workday making use of the knowledge base and skills developed in training. (I wrote about this and referenced some hospitalist time-motion studies in my December 2010 column.)
The remaining hours are typically spent in activities such as figuring out which surgeon is on call and tracking her down, managing patient lists, filling out paper or electronic forms, explaining observation status to patients, and so on.
When I first became a hospitalist in the 1980s, there was already a lot of talk about the paperwork burden faced by doctors across all specialties. I recall the gnashing of teeth that ensued—lots of articles and seminars, and it seems to me even a few legislative proposals, focused on the topic. It appears that nearly every recruitment ad at the time mentioned something like “Let us take care of running the business, so you can focus solely on patient care.” Clearly, doctors were seeking relief from the burden of nonclinical work even back then.
I can’t recall reading or hearing anyone talk about the “paperwork” burden of physician practice in the past few years. This isn’t because things have gotten better; in fact, I think the burden of “non-doctoring activities” has steadily increased. We hear less about the problem of excessive paperwork simply because, more recently, it has been framed differently—it is now typically referred to as the problem of too little time spent practicing at the top of license.
Search the Internet for “top of license” and a number of interesting things turn up. Most are healthcare related—maybe other professions don’t use the term—and there are just as many links referring to nurses as physicians. Much is written about the need for primary care physicians to spend more time working at the top of their license, but I couldn’t find anything addressing this issue specifically for hospitalists.
What Can Be Done?
Moving your work as a hospitalist more to the top of your license isn’t a simple thing, and our whole field will need to work on this over time. The most effective interventions will vary some from place to place, but here are some ideas that may be relevant for many hospitalist groups.
Medication reconciliation. I fully support the idea of careful medication reconciliation, but, given that such a large portion of hospitalist patients are on so many medications, this is a time-consuming task. And, in many or most hospitals, the task suffers from diffusion of responsibility; for example, the ED nurse makes only a half-hearted attempt to get an accurate list, and the hospitalist believes that whatever the ED nurse entered into the record regarding patient medications is probably the best obtainable list.
A pharmacy technician stationed in the ED and charged with recording the best obtainable list of medicines on patient arrival can address both of these problems (for more information, the American Society of Health-System Pharmacists offers webinars and other resources on this topic). This would include calling family members, pharmacies, and physician offices for clarification in some cases. Hospitalists working in such an environment nearly always say it is extremely valuable in reducing inaccuracies in the pre-hospital medication list, as well as saving hospitalists time when they are admitting patients.
Unfortunately, hospitals may resist adding pharmacy technicians because of the expense or, in some cases, because of concerns that such work may exceed the legal scope of work for technicians.
Post-hospital appointments. I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a complete blood count (CBC). It shouldn’t matter whether I want the patient to follow up with the PCP he has been seeing for years, or see a neurologist or diabetes educator as a new patient consult. Any treating doctor in the hospital should be able to arrange such post-hospital visits with just a click or two in the EHR, or a stroke of the pen. And the patient should leave the hospital with a written date and time of the appointment that has been made for them.
Few hospitals can reliably provide this, however, so, all too often, hospitalists spend their time calling clerical staff at outpatient clinics to arrange appointments, writing them down, and delivering them to patients. This is far from what anyone would consider top of license work. (I wrote a little more about this in last month’s column.)
Medicare benefits specialist. Many hospitalists end up spending significant time explaining to patients and families the reason a patient is on observation status and trying to defuse the resulting frustration and anger. As I stated in my November 2014 column, I think observation status is so frustrating to patients that it is often the root cause of complaints about care and, potentially, the source of malpractice suits.
Physicians have an unavoidable role in determining observation versus inpatient status, but I think hospitals should work hard to ensure that someone other than the doctor is available to explain to patients and families the reason for observation status, along with its implications, and to provide sympathy for their frustrations. This allows the doctor to stay focused on clinical care.
Limit reliance on a “triage hospitalist.” Hospitalist groups larger than about 20 providers often have one provider devoted through much of a daytime shift to triaging and assigning new referrals across all providers working that day. For larger practices, this triage work may consume all of the provider’s shift, so that person has no time left for clinical care. It is hard for me to see this as top of license work that only a physician or advanced practice clinician can do. In my December 2010 column, I provided some potential alternatives to dedicating a physician or other provider to a triage role.
Your list of important changes that are needed to move hospitalists toward more time spent working at the top of their license will likely differ a lot from the issues above. But every group could benefit from deliberately thinking about what would be most valuable for them and trying to make that a reality.
Hospitalists spend too little time working at the top of their license. Put differently, I think a hospitalist often spends only about 1.5 to two hours in a 10- or 12-hour workday making use of the knowledge base and skills developed in training. (I wrote about this and referenced some hospitalist time-motion studies in my December 2010 column.)
The remaining hours are typically spent in activities such as figuring out which surgeon is on call and tracking her down, managing patient lists, filling out paper or electronic forms, explaining observation status to patients, and so on.
When I first became a hospitalist in the 1980s, there was already a lot of talk about the paperwork burden faced by doctors across all specialties. I recall the gnashing of teeth that ensued—lots of articles and seminars, and it seems to me even a few legislative proposals, focused on the topic. It appears that nearly every recruitment ad at the time mentioned something like “Let us take care of running the business, so you can focus solely on patient care.” Clearly, doctors were seeking relief from the burden of nonclinical work even back then.
I can’t recall reading or hearing anyone talk about the “paperwork” burden of physician practice in the past few years. This isn’t because things have gotten better; in fact, I think the burden of “non-doctoring activities” has steadily increased. We hear less about the problem of excessive paperwork simply because, more recently, it has been framed differently—it is now typically referred to as the problem of too little time spent practicing at the top of license.
Search the Internet for “top of license” and a number of interesting things turn up. Most are healthcare related—maybe other professions don’t use the term—and there are just as many links referring to nurses as physicians. Much is written about the need for primary care physicians to spend more time working at the top of their license, but I couldn’t find anything addressing this issue specifically for hospitalists.
What Can Be Done?
Moving your work as a hospitalist more to the top of your license isn’t a simple thing, and our whole field will need to work on this over time. The most effective interventions will vary some from place to place, but here are some ideas that may be relevant for many hospitalist groups.
Medication reconciliation. I fully support the idea of careful medication reconciliation, but, given that such a large portion of hospitalist patients are on so many medications, this is a time-consuming task. And, in many or most hospitals, the task suffers from diffusion of responsibility; for example, the ED nurse makes only a half-hearted attempt to get an accurate list, and the hospitalist believes that whatever the ED nurse entered into the record regarding patient medications is probably the best obtainable list.
A pharmacy technician stationed in the ED and charged with recording the best obtainable list of medicines on patient arrival can address both of these problems (for more information, the American Society of Health-System Pharmacists offers webinars and other resources on this topic). This would include calling family members, pharmacies, and physician offices for clarification in some cases. Hospitalists working in such an environment nearly always say it is extremely valuable in reducing inaccuracies in the pre-hospital medication list, as well as saving hospitalists time when they are admitting patients.
Unfortunately, hospitals may resist adding pharmacy technicians because of the expense or, in some cases, because of concerns that such work may exceed the legal scope of work for technicians.
Post-hospital appointments. I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a complete blood count (CBC). It shouldn’t matter whether I want the patient to follow up with the PCP he has been seeing for years, or see a neurologist or diabetes educator as a new patient consult. Any treating doctor in the hospital should be able to arrange such post-hospital visits with just a click or two in the EHR, or a stroke of the pen. And the patient should leave the hospital with a written date and time of the appointment that has been made for them.
Few hospitals can reliably provide this, however, so, all too often, hospitalists spend their time calling clerical staff at outpatient clinics to arrange appointments, writing them down, and delivering them to patients. This is far from what anyone would consider top of license work. (I wrote a little more about this in last month’s column.)
Medicare benefits specialist. Many hospitalists end up spending significant time explaining to patients and families the reason a patient is on observation status and trying to defuse the resulting frustration and anger. As I stated in my November 2014 column, I think observation status is so frustrating to patients that it is often the root cause of complaints about care and, potentially, the source of malpractice suits.
Physicians have an unavoidable role in determining observation versus inpatient status, but I think hospitals should work hard to ensure that someone other than the doctor is available to explain to patients and families the reason for observation status, along with its implications, and to provide sympathy for their frustrations. This allows the doctor to stay focused on clinical care.
Limit reliance on a “triage hospitalist.” Hospitalist groups larger than about 20 providers often have one provider devoted through much of a daytime shift to triaging and assigning new referrals across all providers working that day. For larger practices, this triage work may consume all of the provider’s shift, so that person has no time left for clinical care. It is hard for me to see this as top of license work that only a physician or advanced practice clinician can do. In my December 2010 column, I provided some potential alternatives to dedicating a physician or other provider to a triage role.
Your list of important changes that are needed to move hospitalists toward more time spent working at the top of their license will likely differ a lot from the issues above. But every group could benefit from deliberately thinking about what would be most valuable for them and trying to make that a reality.
Hospitalists spend too little time working at the top of their license. Put differently, I think a hospitalist often spends only about 1.5 to two hours in a 10- or 12-hour workday making use of the knowledge base and skills developed in training. (I wrote about this and referenced some hospitalist time-motion studies in my December 2010 column.)
The remaining hours are typically spent in activities such as figuring out which surgeon is on call and tracking her down, managing patient lists, filling out paper or electronic forms, explaining observation status to patients, and so on.
When I first became a hospitalist in the 1980s, there was already a lot of talk about the paperwork burden faced by doctors across all specialties. I recall the gnashing of teeth that ensued—lots of articles and seminars, and it seems to me even a few legislative proposals, focused on the topic. It appears that nearly every recruitment ad at the time mentioned something like “Let us take care of running the business, so you can focus solely on patient care.” Clearly, doctors were seeking relief from the burden of nonclinical work even back then.
I can’t recall reading or hearing anyone talk about the “paperwork” burden of physician practice in the past few years. This isn’t because things have gotten better; in fact, I think the burden of “non-doctoring activities” has steadily increased. We hear less about the problem of excessive paperwork simply because, more recently, it has been framed differently—it is now typically referred to as the problem of too little time spent practicing at the top of license.
Search the Internet for “top of license” and a number of interesting things turn up. Most are healthcare related—maybe other professions don’t use the term—and there are just as many links referring to nurses as physicians. Much is written about the need for primary care physicians to spend more time working at the top of their license, but I couldn’t find anything addressing this issue specifically for hospitalists.
What Can Be Done?
Moving your work as a hospitalist more to the top of your license isn’t a simple thing, and our whole field will need to work on this over time. The most effective interventions will vary some from place to place, but here are some ideas that may be relevant for many hospitalist groups.
Medication reconciliation. I fully support the idea of careful medication reconciliation, but, given that such a large portion of hospitalist patients are on so many medications, this is a time-consuming task. And, in many or most hospitals, the task suffers from diffusion of responsibility; for example, the ED nurse makes only a half-hearted attempt to get an accurate list, and the hospitalist believes that whatever the ED nurse entered into the record regarding patient medications is probably the best obtainable list.
A pharmacy technician stationed in the ED and charged with recording the best obtainable list of medicines on patient arrival can address both of these problems (for more information, the American Society of Health-System Pharmacists offers webinars and other resources on this topic). This would include calling family members, pharmacies, and physician offices for clarification in some cases. Hospitalists working in such an environment nearly always say it is extremely valuable in reducing inaccuracies in the pre-hospital medication list, as well as saving hospitalists time when they are admitting patients.
Unfortunately, hospitals may resist adding pharmacy technicians because of the expense or, in some cases, because of concerns that such work may exceed the legal scope of work for technicians.
Post-hospital appointments. I think arranging post-hospital appointments should be no more difficult for the hospitalist than ordering a complete blood count (CBC). It shouldn’t matter whether I want the patient to follow up with the PCP he has been seeing for years, or see a neurologist or diabetes educator as a new patient consult. Any treating doctor in the hospital should be able to arrange such post-hospital visits with just a click or two in the EHR, or a stroke of the pen. And the patient should leave the hospital with a written date and time of the appointment that has been made for them.
Few hospitals can reliably provide this, however, so, all too often, hospitalists spend their time calling clerical staff at outpatient clinics to arrange appointments, writing them down, and delivering them to patients. This is far from what anyone would consider top of license work. (I wrote a little more about this in last month’s column.)
Medicare benefits specialist. Many hospitalists end up spending significant time explaining to patients and families the reason a patient is on observation status and trying to defuse the resulting frustration and anger. As I stated in my November 2014 column, I think observation status is so frustrating to patients that it is often the root cause of complaints about care and, potentially, the source of malpractice suits.
Physicians have an unavoidable role in determining observation versus inpatient status, but I think hospitals should work hard to ensure that someone other than the doctor is available to explain to patients and families the reason for observation status, along with its implications, and to provide sympathy for their frustrations. This allows the doctor to stay focused on clinical care.
Limit reliance on a “triage hospitalist.” Hospitalist groups larger than about 20 providers often have one provider devoted through much of a daytime shift to triaging and assigning new referrals across all providers working that day. For larger practices, this triage work may consume all of the provider’s shift, so that person has no time left for clinical care. It is hard for me to see this as top of license work that only a physician or advanced practice clinician can do. In my December 2010 column, I provided some potential alternatives to dedicating a physician or other provider to a triage role.
Your list of important changes that are needed to move hospitalists toward more time spent working at the top of their license will likely differ a lot from the issues above. But every group could benefit from deliberately thinking about what would be most valuable for them and trying to make that a reality.