Practice Economics

Dr. Hospitalist

I just read your article regarding billing. My supervising physician is a surgeon. She and I are both employed by the same hospital. Can she have me dictate the discharge summary before she signs off on it? Or does she have to dictate it because it is in the global post-op period and she is paid for the surgery? If she has me perform an inpatient consult one afternoon/evening, but she doesn't lay eyes on the patient until the following morning, can she bill for the initial consult? Or does she bill for the first subsequent consult? Where is the information to back up your responses, please?

—Concerned with Coding

Dr. Hospitalist responds:

You don’t say so, but I’m assuming you work as a physician assistant (PA) or a nurse practitioner (NP). Since you and your supervising physician are employed by the same hospital, I also assume your fees are assigned to the hospital and you are both considered members of the same “surgical group.”

Just so we’re all on the same page, let’s further define “global surgical” period. Even though there are three types of global surgical packages, they are all based on the number of expected post-operative days. In general, there are the zero- and 10-day post-op periods (for minor procedures) and the 90-day post-op period (for most major procedures). Almost all services, supplies, wound management, and follow-up visits related to the procedure are included in the global surgery payment.

The discharge summary also is part of the global surgery package. When your supervising physician co-signs and validates your note, she can bill as though she did the note herself as defined in the scope of practice and credentialing process at your hospital.

If allowed by your state and sanctioned by your hospital, you can bill separately; however, the global surgery payment would be decreased as per the Medicare Claims Processing Manual (Chapter 12, Sections 40 and 40.1-Physician/Nonphysician Practitioners), which states that “when a NP, PA, or CNS furnish services to a patient during a global surgical period, contractors shall determine the level of NP [nurse practitioner], PA [physician assistant], or CNS [clinical nurse specialist] involvement in furnishing part of the surgeon’s global surgical package consistent with their current practice of processing such claims.” The manual goes on to say that those NP, PA, or CNS services furnished are paid at 80% of the lesser of the actual charge or 85% of what a physician is paid under the Medicare Physician Fee Schedule.

Now you see why it’s more lucrative for the physician to bill than the NP/PA, especially if the extender is working under the “supervision” of the physician.

As I’m sure you’re aware, effective Jan. 1, 2010, the consultation codes were no longer recognized for Medicare Part B payment. Practitioners are directed to code patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs and identify the complexity of the visit performed.

Medicare directives are pretty clear that in order to bill for a visit, the physician or clinician must have a “face-to-face” encounter with the patient on the day of service billed. There is an opportunity for the physician and NP/PA from the same group practice to bill a split/shared E/M code under either unique physician identification number (UPIN), but the physician must still have a face-to-face encounter on the day of service or the bill must be submitted using the NP/PA’s UPIN (Medicare Claims Processing Manual, Chapter 12 – Physician/Nonphysician Practitioners. Section 30.6.1-Selection of Level of Evaluation and Management Service. Implemented: 01-04-10).

Therefore, in the situation that you describe, the supervising physician must bill for a subsequent visit E/M code.

Occasionally, teaching institutions with residents have formalized agreements with insurers that allow residents to see patients one day, with the attending physician allowed to bill for that day without seeing the patient. You should check with your group’s billing specialist to see if such arrangements have been made for your group.

After taking all this into consideration, however, I perceive the bigger issue as underlying tension or mistrust between you and the supervising physician. I suggest sitting down and having a conversation about scope of practice and expectations, and then you can better determine if you are the right person for that position.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

I just read your article regarding billing. My supervising physician is a surgeon. She and I are both employed by the same hospital. Can she have me dictate the discharge summary before she signs off on it? Or does she have to dictate it because it is in the global post-op period and she is paid for the surgery? If she has me perform an inpatient consult one afternoon/evening, but she doesn't lay eyes on the patient until the following morning, can she bill for the initial consult? Or does she bill for the first subsequent consult? Where is the information to back up your responses, please?

—Concerned with Coding

Dr. Hospitalist responds:

You don’t say so, but I’m assuming you work as a physician assistant (PA) or a nurse practitioner (NP). Since you and your supervising physician are employed by the same hospital, I also assume your fees are assigned to the hospital and you are both considered members of the same “surgical group.”

Just so we’re all on the same page, let’s further define “global surgical” period. Even though there are three types of global surgical packages, they are all based on the number of expected post-operative days. In general, there are the zero- and 10-day post-op periods (for minor procedures) and the 90-day post-op period (for most major procedures). Almost all services, supplies, wound management, and follow-up visits related to the procedure are included in the global surgery payment.

The discharge summary also is part of the global surgery package. When your supervising physician co-signs and validates your note, she can bill as though she did the note herself as defined in the scope of practice and credentialing process at your hospital.

If allowed by your state and sanctioned by your hospital, you can bill separately; however, the global surgery payment would be decreased as per the Medicare Claims Processing Manual (Chapter 12, Sections 40 and 40.1-Physician/Nonphysician Practitioners), which states that “when a NP, PA, or CNS furnish services to a patient during a global surgical period, contractors shall determine the level of NP [nurse practitioner], PA [physician assistant], or CNS [clinical nurse specialist] involvement in furnishing part of the surgeon’s global surgical package consistent with their current practice of processing such claims.” The manual goes on to say that those NP, PA, or CNS services furnished are paid at 80% of the lesser of the actual charge or 85% of what a physician is paid under the Medicare Physician Fee Schedule.

Now you see why it’s more lucrative for the physician to bill than the NP/PA, especially if the extender is working under the “supervision” of the physician.

As I’m sure you’re aware, effective Jan. 1, 2010, the consultation codes were no longer recognized for Medicare Part B payment. Practitioners are directed to code patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs and identify the complexity of the visit performed.

Medicare directives are pretty clear that in order to bill for a visit, the physician or clinician must have a “face-to-face” encounter with the patient on the day of service billed. There is an opportunity for the physician and NP/PA from the same group practice to bill a split/shared E/M code under either unique physician identification number (UPIN), but the physician must still have a face-to-face encounter on the day of service or the bill must be submitted using the NP/PA’s UPIN (Medicare Claims Processing Manual, Chapter 12 – Physician/Nonphysician Practitioners. Section 30.6.1-Selection of Level of Evaluation and Management Service. Implemented: 01-04-10).

Therefore, in the situation that you describe, the supervising physician must bill for a subsequent visit E/M code.

Occasionally, teaching institutions with residents have formalized agreements with insurers that allow residents to see patients one day, with the attending physician allowed to bill for that day without seeing the patient. You should check with your group’s billing specialist to see if such arrangements have been made for your group.

After taking all this into consideration, however, I perceive the bigger issue as underlying tension or mistrust between you and the supervising physician. I suggest sitting down and having a conversation about scope of practice and expectations, and then you can better determine if you are the right person for that position.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

I just read your article regarding billing. My supervising physician is a surgeon. She and I are both employed by the same hospital. Can she have me dictate the discharge summary before she signs off on it? Or does she have to dictate it because it is in the global post-op period and she is paid for the surgery? If she has me perform an inpatient consult one afternoon/evening, but she doesn't lay eyes on the patient until the following morning, can she bill for the initial consult? Or does she bill for the first subsequent consult? Where is the information to back up your responses, please?

—Concerned with Coding

Dr. Hospitalist responds:

You don’t say so, but I’m assuming you work as a physician assistant (PA) or a nurse practitioner (NP). Since you and your supervising physician are employed by the same hospital, I also assume your fees are assigned to the hospital and you are both considered members of the same “surgical group.”

Just so we’re all on the same page, let’s further define “global surgical” period. Even though there are three types of global surgical packages, they are all based on the number of expected post-operative days. In general, there are the zero- and 10-day post-op periods (for minor procedures) and the 90-day post-op period (for most major procedures). Almost all services, supplies, wound management, and follow-up visits related to the procedure are included in the global surgery payment.

The discharge summary also is part of the global surgery package. When your supervising physician co-signs and validates your note, she can bill as though she did the note herself as defined in the scope of practice and credentialing process at your hospital.

If allowed by your state and sanctioned by your hospital, you can bill separately; however, the global surgery payment would be decreased as per the Medicare Claims Processing Manual (Chapter 12, Sections 40 and 40.1-Physician/Nonphysician Practitioners), which states that “when a NP, PA, or CNS furnish services to a patient during a global surgical period, contractors shall determine the level of NP [nurse practitioner], PA [physician assistant], or CNS [clinical nurse specialist] involvement in furnishing part of the surgeon’s global surgical package consistent with their current practice of processing such claims.” The manual goes on to say that those NP, PA, or CNS services furnished are paid at 80% of the lesser of the actual charge or 85% of what a physician is paid under the Medicare Physician Fee Schedule.

Now you see why it’s more lucrative for the physician to bill than the NP/PA, especially if the extender is working under the “supervision” of the physician.

As I’m sure you’re aware, effective Jan. 1, 2010, the consultation codes were no longer recognized for Medicare Part B payment. Practitioners are directed to code patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs and identify the complexity of the visit performed.

Medicare directives are pretty clear that in order to bill for a visit, the physician or clinician must have a “face-to-face” encounter with the patient on the day of service billed. There is an opportunity for the physician and NP/PA from the same group practice to bill a split/shared E/M code under either unique physician identification number (UPIN), but the physician must still have a face-to-face encounter on the day of service or the bill must be submitted using the NP/PA’s UPIN (Medicare Claims Processing Manual, Chapter 12 – Physician/Nonphysician Practitioners. Section 30.6.1-Selection of Level of Evaluation and Management Service. Implemented: 01-04-10).

Therefore, in the situation that you describe, the supervising physician must bill for a subsequent visit E/M code.

Occasionally, teaching institutions with residents have formalized agreements with insurers that allow residents to see patients one day, with the attending physician allowed to bill for that day without seeing the patient. You should check with your group’s billing specialist to see if such arrangements have been made for your group.

After taking all this into consideration, however, I perceive the bigger issue as underlying tension or mistrust between you and the supervising physician. I suggest sitting down and having a conversation about scope of practice and expectations, and then you can better determine if you are the right person for that position.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Nelson

Dr. Nelson

I hope you’re already familiar with “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” [www.hospitalmedicine.org/keychar] and have spent at least a few minutes reviewing the list of 10 “principles” and 47 “characteristics” thought to be associated with effective hospital medicine groups (HMGs). (Full disclosure: I was one of the authors of the article published in February 2014 in the Journal of Hospital Medicine.) Most of us are very busy, so the temptation might be high to set the article aside and risk forgetting it. But I hope many in our field, both clinicians and administrators, will look at it more carefully. There are a number of ways you could use the guide to stimulate thinking or change in your practice.

Grading Our Specialty

I just returned from a meeting of about 10 hospitalist leaders from different organizations around the country. Attendees represented the diversity of our field, including hospital-employed HMGs, large hospitalist management companies, and academic programs. We spent a portion of the meeting discussing what grade we as a group would give the whole specialty of hospital medicine on each of the 10 “principles.” Essentially, we generated a report card for the U.S. hospitalist movement.

This wasn’t a rigorous scientific exercise; instead, it was a robust and thought-provoking discussion around what grade to assign. Opinions regarding the appropriate grade varied significantly, but a common theme was that our specialty really “owns” the importance of pursuing many or most of the principles listed in the article and is devoting time and resources to them even if many individual HMGs might have a long way to go to perform optimally.

For example, meeting attendees thought our field has for a long time worked diligently to “support care coordination across the care continuum” (Principle 6). No one thought that all HMGs do this optimally, but the consensus was that most HMGs have invested effort to do it well. And most were concerned that many HMGs still lack “adequate resources” (Principle 3) and sufficiently “engaged hospitalists” (Principle 2)—and that the former contributes to the latter.

The opinion of the hospitalist leaders who happened to attend the meeting where this conversation took place doesn’t represent the final word on how our specialty is performing, but I think all involved found value in having the conversation, hearing different perspectives about what we’re doing well and where we should focus energy and resources to improve.

Grading Your HM Group

You might want to do something similar within your own group, but make it more relevant by grading how your own practice performs on each of the 10 principles. You could do this on your own just to stimulate your thinking, or you could have each member of your HMG generate a report card of your group’s performance—then discuss where there is agreement or disagreement within the group.

You could structure this sort of individual or group assessment simply as an exercise to generate ideas and conversation about the practice, or your group could take a more formal approach and use it as part of a planning process to determine future practice management-related goals. I know of some groups that scheduled strategic planning meetings specifically to discuss which of the elements to make a priority.

Discussion Document for Leadership

In addition to using the article to generate conversation among hospitalists within your group, it can be a really valuable tool in guiding conversations with hospital leaders and the entity that employs the hospitalists. For example, you could use the article to generate or update the job description of the lead hospitalist or practice manager. Or during annual budgeting for the hospitalist practice, the guide could be used as a checklist to think about whether there are important areas that would benefit from more resources.

Of course, there is a risk that hospital leaders or those who employ the hospitalists could use the article primarily to criticize a hospitalist group and its leader for not already having excellent performance on every one of the principles and characteristics listed. That would be pretty unfortunate; there probably isn’t a single group that performs well on every domain, and the real value of the article is to “be aspirational, helping to raise the bar” for each HMG and our specialty as a whole.

And, as discussed in the article, an HMG doesn’t need to be a stellar performer on all 47 characteristics to be effective. Some of the characteristics listed in the article may not apply to all groups, so all involved in the management of any individual HMG should think about whether to set some aside when assessing their own group.

Where to Go from Here

The article is based on expert opinion, with the help of many more people than those listed as author, and I’m hopeful it will stimulate researchers to study some of these principles and characteristics. For many reasons, we will probably never have robust data, but I’d be happy for whatever we can get.

There is a pretty good chance that the evolution in the work we do and the nature of the hospital setting mean that the principles and characteristics may need to be revised periodically. I would love to know how they might be different in 10 or 20 years.

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].

Dr. Nelson

Dr. Nelson

I hope you’re already familiar with “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” [www.hospitalmedicine.org/keychar] and have spent at least a few minutes reviewing the list of 10 “principles” and 47 “characteristics” thought to be associated with effective hospital medicine groups (HMGs). (Full disclosure: I was one of the authors of the article published in February 2014 in the Journal of Hospital Medicine.) Most of us are very busy, so the temptation might be high to set the article aside and risk forgetting it. But I hope many in our field, both clinicians and administrators, will look at it more carefully. There are a number of ways you could use the guide to stimulate thinking or change in your practice.

Grading Our Specialty

I just returned from a meeting of about 10 hospitalist leaders from different organizations around the country. Attendees represented the diversity of our field, including hospital-employed HMGs, large hospitalist management companies, and academic programs. We spent a portion of the meeting discussing what grade we as a group would give the whole specialty of hospital medicine on each of the 10 “principles.” Essentially, we generated a report card for the U.S. hospitalist movement.

This wasn’t a rigorous scientific exercise; instead, it was a robust and thought-provoking discussion around what grade to assign. Opinions regarding the appropriate grade varied significantly, but a common theme was that our specialty really “owns” the importance of pursuing many or most of the principles listed in the article and is devoting time and resources to them even if many individual HMGs might have a long way to go to perform optimally.

For example, meeting attendees thought our field has for a long time worked diligently to “support care coordination across the care continuum” (Principle 6). No one thought that all HMGs do this optimally, but the consensus was that most HMGs have invested effort to do it well. And most were concerned that many HMGs still lack “adequate resources” (Principle 3) and sufficiently “engaged hospitalists” (Principle 2)—and that the former contributes to the latter.

The opinion of the hospitalist leaders who happened to attend the meeting where this conversation took place doesn’t represent the final word on how our specialty is performing, but I think all involved found value in having the conversation, hearing different perspectives about what we’re doing well and where we should focus energy and resources to improve.

Grading Your HM Group

You might want to do something similar within your own group, but make it more relevant by grading how your own practice performs on each of the 10 principles. You could do this on your own just to stimulate your thinking, or you could have each member of your HMG generate a report card of your group’s performance—then discuss where there is agreement or disagreement within the group.

You could structure this sort of individual or group assessment simply as an exercise to generate ideas and conversation about the practice, or your group could take a more formal approach and use it as part of a planning process to determine future practice management-related goals. I know of some groups that scheduled strategic planning meetings specifically to discuss which of the elements to make a priority.

Discussion Document for Leadership

In addition to using the article to generate conversation among hospitalists within your group, it can be a really valuable tool in guiding conversations with hospital leaders and the entity that employs the hospitalists. For example, you could use the article to generate or update the job description of the lead hospitalist or practice manager. Or during annual budgeting for the hospitalist practice, the guide could be used as a checklist to think about whether there are important areas that would benefit from more resources.

Of course, there is a risk that hospital leaders or those who employ the hospitalists could use the article primarily to criticize a hospitalist group and its leader for not already having excellent performance on every one of the principles and characteristics listed. That would be pretty unfortunate; there probably isn’t a single group that performs well on every domain, and the real value of the article is to “be aspirational, helping to raise the bar” for each HMG and our specialty as a whole.

And, as discussed in the article, an HMG doesn’t need to be a stellar performer on all 47 characteristics to be effective. Some of the characteristics listed in the article may not apply to all groups, so all involved in the management of any individual HMG should think about whether to set some aside when assessing their own group.

Where to Go from Here

The article is based on expert opinion, with the help of many more people than those listed as author, and I’m hopeful it will stimulate researchers to study some of these principles and characteristics. For many reasons, we will probably never have robust data, but I’d be happy for whatever we can get.

There is a pretty good chance that the evolution in the work we do and the nature of the hospital setting mean that the principles and characteristics may need to be revised periodically. I would love to know how they might be different in 10 or 20 years.

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].

Dr. Nelson

Dr. Nelson

I hope you’re already familiar with “The Key Principles and Characteristics of an Effective Hospital Medicine Group: An Assessment Guide for Hospitals and Hospitalists” [www.hospitalmedicine.org/keychar] and have spent at least a few minutes reviewing the list of 10 “principles” and 47 “characteristics” thought to be associated with effective hospital medicine groups (HMGs). (Full disclosure: I was one of the authors of the article published in February 2014 in the Journal of Hospital Medicine.) Most of us are very busy, so the temptation might be high to set the article aside and risk forgetting it. But I hope many in our field, both clinicians and administrators, will look at it more carefully. There are a number of ways you could use the guide to stimulate thinking or change in your practice.

Grading Our Specialty

I just returned from a meeting of about 10 hospitalist leaders from different organizations around the country. Attendees represented the diversity of our field, including hospital-employed HMGs, large hospitalist management companies, and academic programs. We spent a portion of the meeting discussing what grade we as a group would give the whole specialty of hospital medicine on each of the 10 “principles.” Essentially, we generated a report card for the U.S. hospitalist movement.

This wasn’t a rigorous scientific exercise; instead, it was a robust and thought-provoking discussion around what grade to assign. Opinions regarding the appropriate grade varied significantly, but a common theme was that our specialty really “owns” the importance of pursuing many or most of the principles listed in the article and is devoting time and resources to them even if many individual HMGs might have a long way to go to perform optimally.

For example, meeting attendees thought our field has for a long time worked diligently to “support care coordination across the care continuum” (Principle 6). No one thought that all HMGs do this optimally, but the consensus was that most HMGs have invested effort to do it well. And most were concerned that many HMGs still lack “adequate resources” (Principle 3) and sufficiently “engaged hospitalists” (Principle 2)—and that the former contributes to the latter.

The opinion of the hospitalist leaders who happened to attend the meeting where this conversation took place doesn’t represent the final word on how our specialty is performing, but I think all involved found value in having the conversation, hearing different perspectives about what we’re doing well and where we should focus energy and resources to improve.

Grading Your HM Group

You might want to do something similar within your own group, but make it more relevant by grading how your own practice performs on each of the 10 principles. You could do this on your own just to stimulate your thinking, or you could have each member of your HMG generate a report card of your group’s performance—then discuss where there is agreement or disagreement within the group.

You could structure this sort of individual or group assessment simply as an exercise to generate ideas and conversation about the practice, or your group could take a more formal approach and use it as part of a planning process to determine future practice management-related goals. I know of some groups that scheduled strategic planning meetings specifically to discuss which of the elements to make a priority.

Discussion Document for Leadership

In addition to using the article to generate conversation among hospitalists within your group, it can be a really valuable tool in guiding conversations with hospital leaders and the entity that employs the hospitalists. For example, you could use the article to generate or update the job description of the lead hospitalist or practice manager. Or during annual budgeting for the hospitalist practice, the guide could be used as a checklist to think about whether there are important areas that would benefit from more resources.

Of course, there is a risk that hospital leaders or those who employ the hospitalists could use the article primarily to criticize a hospitalist group and its leader for not already having excellent performance on every one of the principles and characteristics listed. That would be pretty unfortunate; there probably isn’t a single group that performs well on every domain, and the real value of the article is to “be aspirational, helping to raise the bar” for each HMG and our specialty as a whole.

And, as discussed in the article, an HMG doesn’t need to be a stellar performer on all 47 characteristics to be effective. Some of the characteristics listed in the article may not apply to all groups, so all involved in the management of any individual HMG should think about whether to set some aside when assessing their own group.

Where to Go from Here

The article is based on expert opinion, with the help of many more people than those listed as author, and I’m hopeful it will stimulate researchers to study some of these principles and characteristics. For many reasons, we will probably never have robust data, but I’d be happy for whatever we can get.

There is a pretty good chance that the evolution in the work we do and the nature of the hospital setting mean that the principles and characteristics may need to be revised periodically. I would love to know how they might be different in 10 or 20 years.

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: This is the first of two articles from SHM’s Health Information Technology committee offering practical recommendations for improving electronic health records (EHRs) to reduce readmissions, along with practice-based vignettes to support the recommendations.

Despite limited support from the medical literature, hospital teams know that technology, specifically electronic health record (EHR) technology, can improve healthcare quality. Given 2009’s Health Information Technology for Economic and Clinical Health (HITECH) Act, the federal government is betting on this as well. These hospital teams, often led by hospitalists, are charged with creating workflows and EHR build that will affect measurable quality indicators. Hospital finances, tied to Medicare pay-for-performance incentives, hang in the balance.

As a hospitalist and chairperson of SHM’s IT Quality Subcommittee, I helped lead an effort to examine how technology and EHRs could be used to reduce readmissions. The subcommittee was composed of eight hospitalists from around the country and two mentors, Jerome Osheroff, MD, FACMI, of TMIT Consulting, and Kendall Rogers, MD, CPE, FACP, FHM, of the University of New Mexico. The goal of this effort was to create reproducible models of how EHR and technology in general could be leveraged to reduce readmissions.

Members of the committee initially were asked to evaluate all-cause, 30-day readmissions at their respective institutions. Any hospital with a readmissions rate less than 16% over the previous year was considered “high performing.” Members were asked to advocate for one technology/EHR intervention that had the most impact locally. Interventions were vetted within the committee and based on literature review.

Specific categories evaluated included:

• Readmission risk assessment;
• Communication with referring physicians;
• Medication reconciliation;
• Multidisciplinary rounds;
• Patient education;
• Discharge coaches;
• Patient-centric discharge paperwork;
• Post-discharge coordination of care; and
• Medication compliance.

These site-specific experiences could be considered “springboards” for randomized trials of likely successful interventions.

Recommendation: Use readmission risk assessment to apply resources to most appropriate patients.

Ned Jaleel, DO, MMM, CPE, a hospitalist and informaticist for Meditech Corp., and Maruf Haider, MD, a hospitalist and informaticist for INOVA Healthcare, have mapped implemented processes for real-time assessment of readmission risk stratification and “measurevention” based on this data.

Augusta Health in Fishersville, Va., uses Meditech EHR to extract relevant data about risk assessment and display this data to case managers using the LACE model (length of stay, acuity, comorbidities, ER visits). The modified LACE model included medication information to create a readmission risk score. Case managers can then determine which patients require the most care and attention from the multidisciplinary team.

Dr. Haider has taken this process a step further by using the LACE score to determine the need for specific tiered intervention based on established risk. Average risk patients are simply set up with a follow-up appointment within seven days. Higher risk patients are set up with health coaching, home nursing, or more intense inpatient multidisciplinary rounds based on four tiers of risk stratification. Risk stratification is discussed on rounds, and providers are requested to order the additional services. Patients referred to transitional services had a 6.5% readmission rate compared to the hospitalist groups overall at 15.6%.

Recommendation: Use electronic communication to increase reliability of contact with primary care physicians.

At Lahey Health System in Burlington, Mass., I knew that hospitalists needed to improve communication with PCPs. Telephone communication was unreliable, and discharge summaries were not being delivered to referring physicians in a timely fashion.

The hospitalists already were using a homegrown “patient handoff report” to track currently admitted patients, along with clinical summaries. A decision was made that secure e-mail, driven by data in the handoff reports, could provide the solution. Because the system was between inpatient EHR vendors, it would need to be developed by in-house IT services. A specific challenge would be referring physicians with no attachment to the health system.

Using a secure messaging vendor (ZixCorp), we were able to create e-mail messages to referring physicians using data already in the handoff system to avoid duplication of data entry. The benefit to referring physicians was the brevity and timeliness of the data and the ability to ask questions directly via return e-mail. Fortunately, we were able to request enough e-mails to ensure that the majority of patients with non-system physicians would allow this type of communication. This and other interventions have allowed Lahey to reduce 30-day readmissions to less than 15%.

Recommendation: Use pharmacy resources to improve quality of medication reconciliation.

Rupesh Prasad, MD, MPH, of Aurora Healthcare in Milwaukee, Wisconsin, has spent part of his professional career optimizing medication reconciliation. The key has been incorporating EHR workflows that allow pharmacy to take an active role in medication reconciliation.

Initially, pharmacy technicians collect the home medication list using information from pharmacy, patient and family, and primary physician and enter into the system. This allows the admitting provider to perform the most accurate medication reconciliation possible. The EHR has allowed more accurate sharing of medication lists across inpatient and outpatient care areas and helped to prevent dosing errors and duplication via decision support. The discharge materials provide information in a patient-centric manner that helps reduce medication errors at home. These and other interventions have helped reduce readmission at Aurora to less than 16% at 30 days.

Recommendation: Use EHR resources to support BOOST rounds to improve collaboration.

Gaurav Chaturvedi, MD, of Northwestern Lake Forest Hospital in Lake Forest, Ill., has used his Cerner EHR in collaboration with SHM’s Project BOOST to reduce readmission in 2013 to a very impressive 11% at 30 days.

The key to success is daily multidisciplinary rounds at the bedside involving all members of the care team, including physicians, nurses, case managers, pharmacy, physical therapy, and social work. This ensures that all members of the care team, including the patient and family, are up to date on the care plan at the same time. The EHR has supported this process through creation of templates that pull in critical information for rounds such as ambulation, central lines, VTE prophylaxis, Foley, and medication reconciliation.

With all of the information readily available in the same template for rounds, the team can focus efficiently on the goals of care and discharge needs required to prevent readmissions.

Recommendation: Improve patient education by integrating with discharge workflows.

Dr. Chaturvedi also has experience integrating patient education into EHR workflows. His initial efforts involved heart failure education and resulted in reduction over 48 months in heart failure readmission rates to 8.3% from 27% at 30 days. Prior to discharge, heart failure patients received a guidebook with the medication summary, appointments, diet, and EHR-integrated educational materials from the Krames StayWell database. This highly successful, partially EHR-based intervention included a scale to promote daily weights.

After EHR implementation in 2012, Lake Forest Hospital needed to leverage similar successful functionality into their Cerner EHR. The hospital worked with Cerner to develop Mpages that allowed seamless multi-provider entry on discharge paperwork. This would include primary and secondary diagnoses and warning signs. These entries would “suggest” Krames’ patient-centric educational materials that would discuss diagnosis and treatment, along with warning signs specific to the diagnosis. TH

Dr. Finkel is a hospitalist at Lahey Hospital and Medical Center in Burlington, Mass. Email questions and comments to [email protected].

Editor’s note: This is the first of two articles from SHM’s Health Information Technology committee offering practical recommendations for improving electronic health records (EHRs) to reduce readmissions, along with practice-based vignettes to support the recommendations.

Despite limited support from the medical literature, hospital teams know that technology, specifically electronic health record (EHR) technology, can improve healthcare quality. Given 2009’s Health Information Technology for Economic and Clinical Health (HITECH) Act, the federal government is betting on this as well. These hospital teams, often led by hospitalists, are charged with creating workflows and EHR build that will affect measurable quality indicators. Hospital finances, tied to Medicare pay-for-performance incentives, hang in the balance.

As a hospitalist and chairperson of SHM’s IT Quality Subcommittee, I helped lead an effort to examine how technology and EHRs could be used to reduce readmissions. The subcommittee was composed of eight hospitalists from around the country and two mentors, Jerome Osheroff, MD, FACMI, of TMIT Consulting, and Kendall Rogers, MD, CPE, FACP, FHM, of the University of New Mexico. The goal of this effort was to create reproducible models of how EHR and technology in general could be leveraged to reduce readmissions.

Members of the committee initially were asked to evaluate all-cause, 30-day readmissions at their respective institutions. Any hospital with a readmissions rate less than 16% over the previous year was considered “high performing.” Members were asked to advocate for one technology/EHR intervention that had the most impact locally. Interventions were vetted within the committee and based on literature review.

Specific categories evaluated included:

• Readmission risk assessment;
• Communication with referring physicians;
• Medication reconciliation;
• Multidisciplinary rounds;
• Patient education;
• Discharge coaches;
• Patient-centric discharge paperwork;
• Post-discharge coordination of care; and
• Medication compliance.

These site-specific experiences could be considered “springboards” for randomized trials of likely successful interventions.

Recommendation: Use readmission risk assessment to apply resources to most appropriate patients.

Ned Jaleel, DO, MMM, CPE, a hospitalist and informaticist for Meditech Corp., and Maruf Haider, MD, a hospitalist and informaticist for INOVA Healthcare, have mapped implemented processes for real-time assessment of readmission risk stratification and “measurevention” based on this data.

Augusta Health in Fishersville, Va., uses Meditech EHR to extract relevant data about risk assessment and display this data to case managers using the LACE model (length of stay, acuity, comorbidities, ER visits). The modified LACE model included medication information to create a readmission risk score. Case managers can then determine which patients require the most care and attention from the multidisciplinary team.

Dr. Haider has taken this process a step further by using the LACE score to determine the need for specific tiered intervention based on established risk. Average risk patients are simply set up with a follow-up appointment within seven days. Higher risk patients are set up with health coaching, home nursing, or more intense inpatient multidisciplinary rounds based on four tiers of risk stratification. Risk stratification is discussed on rounds, and providers are requested to order the additional services. Patients referred to transitional services had a 6.5% readmission rate compared to the hospitalist groups overall at 15.6%.

Recommendation: Use electronic communication to increase reliability of contact with primary care physicians.

At Lahey Health System in Burlington, Mass., I knew that hospitalists needed to improve communication with PCPs. Telephone communication was unreliable, and discharge summaries were not being delivered to referring physicians in a timely fashion.

The hospitalists already were using a homegrown “patient handoff report” to track currently admitted patients, along with clinical summaries. A decision was made that secure e-mail, driven by data in the handoff reports, could provide the solution. Because the system was between inpatient EHR vendors, it would need to be developed by in-house IT services. A specific challenge would be referring physicians with no attachment to the health system.

Using a secure messaging vendor (ZixCorp), we were able to create e-mail messages to referring physicians using data already in the handoff system to avoid duplication of data entry. The benefit to referring physicians was the brevity and timeliness of the data and the ability to ask questions directly via return e-mail. Fortunately, we were able to request enough e-mails to ensure that the majority of patients with non-system physicians would allow this type of communication. This and other interventions have allowed Lahey to reduce 30-day readmissions to less than 15%.

Recommendation: Use pharmacy resources to improve quality of medication reconciliation.

Rupesh Prasad, MD, MPH, of Aurora Healthcare in Milwaukee, Wisconsin, has spent part of his professional career optimizing medication reconciliation. The key has been incorporating EHR workflows that allow pharmacy to take an active role in medication reconciliation.

Initially, pharmacy technicians collect the home medication list using information from pharmacy, patient and family, and primary physician and enter into the system. This allows the admitting provider to perform the most accurate medication reconciliation possible. The EHR has allowed more accurate sharing of medication lists across inpatient and outpatient care areas and helped to prevent dosing errors and duplication via decision support. The discharge materials provide information in a patient-centric manner that helps reduce medication errors at home. These and other interventions have helped reduce readmission at Aurora to less than 16% at 30 days.

Recommendation: Use EHR resources to support BOOST rounds to improve collaboration.

Gaurav Chaturvedi, MD, of Northwestern Lake Forest Hospital in Lake Forest, Ill., has used his Cerner EHR in collaboration with SHM’s Project BOOST to reduce readmission in 2013 to a very impressive 11% at 30 days.

The key to success is daily multidisciplinary rounds at the bedside involving all members of the care team, including physicians, nurses, case managers, pharmacy, physical therapy, and social work. This ensures that all members of the care team, including the patient and family, are up to date on the care plan at the same time. The EHR has supported this process through creation of templates that pull in critical information for rounds such as ambulation, central lines, VTE prophylaxis, Foley, and medication reconciliation.

With all of the information readily available in the same template for rounds, the team can focus efficiently on the goals of care and discharge needs required to prevent readmissions.

Recommendation: Improve patient education by integrating with discharge workflows.

Dr. Chaturvedi also has experience integrating patient education into EHR workflows. His initial efforts involved heart failure education and resulted in reduction over 48 months in heart failure readmission rates to 8.3% from 27% at 30 days. Prior to discharge, heart failure patients received a guidebook with the medication summary, appointments, diet, and EHR-integrated educational materials from the Krames StayWell database. This highly successful, partially EHR-based intervention included a scale to promote daily weights.

After EHR implementation in 2012, Lake Forest Hospital needed to leverage similar successful functionality into their Cerner EHR. The hospital worked with Cerner to develop Mpages that allowed seamless multi-provider entry on discharge paperwork. This would include primary and secondary diagnoses and warning signs. These entries would “suggest” Krames’ patient-centric educational materials that would discuss diagnosis and treatment, along with warning signs specific to the diagnosis. TH

Dr. Finkel is a hospitalist at Lahey Hospital and Medical Center in Burlington, Mass. Email questions and comments to [email protected].

Editor’s note: This is the first of two articles from SHM’s Health Information Technology committee offering practical recommendations for improving electronic health records (EHRs) to reduce readmissions, along with practice-based vignettes to support the recommendations.

Despite limited support from the medical literature, hospital teams know that technology, specifically electronic health record (EHR) technology, can improve healthcare quality. Given 2009’s Health Information Technology for Economic and Clinical Health (HITECH) Act, the federal government is betting on this as well. These hospital teams, often led by hospitalists, are charged with creating workflows and EHR build that will affect measurable quality indicators. Hospital finances, tied to Medicare pay-for-performance incentives, hang in the balance.

As a hospitalist and chairperson of SHM’s IT Quality Subcommittee, I helped lead an effort to examine how technology and EHRs could be used to reduce readmissions. The subcommittee was composed of eight hospitalists from around the country and two mentors, Jerome Osheroff, MD, FACMI, of TMIT Consulting, and Kendall Rogers, MD, CPE, FACP, FHM, of the University of New Mexico. The goal of this effort was to create reproducible models of how EHR and technology in general could be leveraged to reduce readmissions.

Members of the committee initially were asked to evaluate all-cause, 30-day readmissions at their respective institutions. Any hospital with a readmissions rate less than 16% over the previous year was considered “high performing.” Members were asked to advocate for one technology/EHR intervention that had the most impact locally. Interventions were vetted within the committee and based on literature review.

Specific categories evaluated included:

• Readmission risk assessment;
• Communication with referring physicians;
• Medication reconciliation;
• Multidisciplinary rounds;
• Patient education;
• Discharge coaches;
• Patient-centric discharge paperwork;
• Post-discharge coordination of care; and
• Medication compliance.

These site-specific experiences could be considered “springboards” for randomized trials of likely successful interventions.

Recommendation: Use readmission risk assessment to apply resources to most appropriate patients.

Ned Jaleel, DO, MMM, CPE, a hospitalist and informaticist for Meditech Corp., and Maruf Haider, MD, a hospitalist and informaticist for INOVA Healthcare, have mapped implemented processes for real-time assessment of readmission risk stratification and “measurevention” based on this data.

Augusta Health in Fishersville, Va., uses Meditech EHR to extract relevant data about risk assessment and display this data to case managers using the LACE model (length of stay, acuity, comorbidities, ER visits). The modified LACE model included medication information to create a readmission risk score. Case managers can then determine which patients require the most care and attention from the multidisciplinary team.

Dr. Haider has taken this process a step further by using the LACE score to determine the need for specific tiered intervention based on established risk. Average risk patients are simply set up with a follow-up appointment within seven days. Higher risk patients are set up with health coaching, home nursing, or more intense inpatient multidisciplinary rounds based on four tiers of risk stratification. Risk stratification is discussed on rounds, and providers are requested to order the additional services. Patients referred to transitional services had a 6.5% readmission rate compared to the hospitalist groups overall at 15.6%.

Recommendation: Use electronic communication to increase reliability of contact with primary care physicians.

At Lahey Health System in Burlington, Mass., I knew that hospitalists needed to improve communication with PCPs. Telephone communication was unreliable, and discharge summaries were not being delivered to referring physicians in a timely fashion.

The hospitalists already were using a homegrown “patient handoff report” to track currently admitted patients, along with clinical summaries. A decision was made that secure e-mail, driven by data in the handoff reports, could provide the solution. Because the system was between inpatient EHR vendors, it would need to be developed by in-house IT services. A specific challenge would be referring physicians with no attachment to the health system.

Using a secure messaging vendor (ZixCorp), we were able to create e-mail messages to referring physicians using data already in the handoff system to avoid duplication of data entry. The benefit to referring physicians was the brevity and timeliness of the data and the ability to ask questions directly via return e-mail. Fortunately, we were able to request enough e-mails to ensure that the majority of patients with non-system physicians would allow this type of communication. This and other interventions have allowed Lahey to reduce 30-day readmissions to less than 15%.

Recommendation: Use pharmacy resources to improve quality of medication reconciliation.

Rupesh Prasad, MD, MPH, of Aurora Healthcare in Milwaukee, Wisconsin, has spent part of his professional career optimizing medication reconciliation. The key has been incorporating EHR workflows that allow pharmacy to take an active role in medication reconciliation.

Initially, pharmacy technicians collect the home medication list using information from pharmacy, patient and family, and primary physician and enter into the system. This allows the admitting provider to perform the most accurate medication reconciliation possible. The EHR has allowed more accurate sharing of medication lists across inpatient and outpatient care areas and helped to prevent dosing errors and duplication via decision support. The discharge materials provide information in a patient-centric manner that helps reduce medication errors at home. These and other interventions have helped reduce readmission at Aurora to less than 16% at 30 days.

Recommendation: Use EHR resources to support BOOST rounds to improve collaboration.

Gaurav Chaturvedi, MD, of Northwestern Lake Forest Hospital in Lake Forest, Ill., has used his Cerner EHR in collaboration with SHM’s Project BOOST to reduce readmission in 2013 to a very impressive 11% at 30 days.

The key to success is daily multidisciplinary rounds at the bedside involving all members of the care team, including physicians, nurses, case managers, pharmacy, physical therapy, and social work. This ensures that all members of the care team, including the patient and family, are up to date on the care plan at the same time. The EHR has supported this process through creation of templates that pull in critical information for rounds such as ambulation, central lines, VTE prophylaxis, Foley, and medication reconciliation.

With all of the information readily available in the same template for rounds, the team can focus efficiently on the goals of care and discharge needs required to prevent readmissions.

Recommendation: Improve patient education by integrating with discharge workflows.

Dr. Chaturvedi also has experience integrating patient education into EHR workflows. His initial efforts involved heart failure education and resulted in reduction over 48 months in heart failure readmission rates to 8.3% from 27% at 30 days. Prior to discharge, heart failure patients received a guidebook with the medication summary, appointments, diet, and EHR-integrated educational materials from the Krames StayWell database. This highly successful, partially EHR-based intervention included a scale to promote daily weights.

After EHR implementation in 2012, Lake Forest Hospital needed to leverage similar successful functionality into their Cerner EHR. The hospital worked with Cerner to develop Mpages that allowed seamless multi-provider entry on discharge paperwork. This would include primary and secondary diagnoses and warning signs. These entries would “suggest” Krames’ patient-centric educational materials that would discuss diagnosis and treatment, along with warning signs specific to the diagnosis. TH

Dr. Finkel is a hospitalist at Lahey Hospital and Medical Center in Burlington, Mass. Email questions and comments to [email protected].

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

In recent months, numerous articles have come out targeting high-billing physicians—looking for smoking guns in recently released 2012 Medicare fee-for-service physician claims data. These data include both the amount each individual physician billed and the amount Medicare paid on average for services performed by all physicians treating Medicare beneficiaries.

Many physician groups, including the AMA, criticized the data release as having significant limitations, including clinical and billing practice realities that confound the layperson’s understanding of the data’s implications. Still, there is much physicians can learn by exploring this information, particularly those in a still-growing field like hospital medicine (HM).

There is no clear method to identify hospitalists within these data. Hospitalists are dispersed throughout their respective board certifications—internal medicine, family practice, pediatrics. The designations come directly from the Medicare specialty billing code; the code associated with the largest number of services becomes that provider’s de facto specialty. For the majority of providers, this will correspond with their board certification and their professional identity. A hospitalist’s unique practice is lost within these general identifiers.

However, the contours of that unique practice may provide some tools to identify hospitalists, albeit roughly, within the data and in the absence of a specialty billing code. Things like practice location and commonly billed Healthcare Common Procedure Coding System (HCPCS) codes can help sketch the boundaries of the field. Certainly, any classification methodology will have its share of imperfections and may exclude individuals who would otherwise identify as hospitalists. Regardless, such an exercise could identify trends in hospital medicine while providing a better understanding of the field as a whole.

HM does not have the traditional hallmark signifiers—board certification and Medicare specialty billing code—used by many specialties and subspecialties to frame their fields and to classify and compare physicians. The Medicare specialty billing code is a unique code applied to Medicare billing claims that tells Medicare exactly how the provider would like to be identified.

Because of its relative specificity and ready accessibility, the Centers for Medicare and Medicaid Services (CMS) uses the specialty billing code to create specialty comparison groups in pay-for-performance programs. Under the value-based payment modifier, hospitalists are compared against outpatient internal medicine or family medicine physicians, which makes them seem all the more expensive and less efficient.

SHM has been attuned to this particular issue since the early days of the physician value-based payment modifier. For nearly two years, SHM has repeatedly admonished CMS to compare hospitalists against other hospitalists in order for a pay-for-performance scheme to fairly and reasonably evaluate quality and efficiency. CMS acknowledged that many specialties and subspecialties may be masked within the current listing of Medicare specialty billing codes but yielded only so far as to say that aggrieved specialties can apply for their own code. SHM, for its part, applied for a specialty billing code for hospitalists in May 2014.

SHM has been actively exploring the data and looking at ways to identify hospitalists within this Medicare data. There’s an inherent value to this sort of self-reflection—it explains who we are and where we have been.

More importantly, it helps inform where we are going.

Joshua Lapps is SHM’s government relations manager.

Recruiting and retaining hospitalists are major challenges for hospital medicine groups across the country, and the State of Hospital Medicine report can be the roadmap for helping them keep the hospitalists they need.

The State of Hospital Medicine, available in September from SHM, provides a comprehensive data set on compensation and productivity for hospitalists across the country—and across sub-specialties in HM. Using data from the State of Hospital Medicine report, hospitalists everywhere compare their own compensation strategies against those in their region and throughout the U.S.

The latest issue, published by SHM every other year, will be available later this month but can be pre-ordered today. For more information, or to pre-order, visit www.hospitalmedicine.org/sohm.

Recruiting and retaining hospitalists are major challenges for hospital medicine groups across the country, and the State of Hospital Medicine report can be the roadmap for helping them keep the hospitalists they need.

The State of Hospital Medicine, available in September from SHM, provides a comprehensive data set on compensation and productivity for hospitalists across the country—and across sub-specialties in HM. Using data from the State of Hospital Medicine report, hospitalists everywhere compare their own compensation strategies against those in their region and throughout the U.S.

The latest issue, published by SHM every other year, will be available later this month but can be pre-ordered today. For more information, or to pre-order, visit www.hospitalmedicine.org/sohm.

Recruiting and retaining hospitalists are major challenges for hospital medicine groups across the country, and the State of Hospital Medicine report can be the roadmap for helping them keep the hospitalists they need.

The State of Hospital Medicine, available in September from SHM, provides a comprehensive data set on compensation and productivity for hospitalists across the country—and across sub-specialties in HM. Using data from the State of Hospital Medicine report, hospitalists everywhere compare their own compensation strategies against those in their region and throughout the U.S.

The latest issue, published by SHM every other year, will be available later this month but can be pre-ordered today. For more information, or to pre-order, visit www.hospitalmedicine.org/sohm.

Have you ever worried about which billing code is appropriate? Worried that your coding decisions could be called into question, but reading up on the topic only left you more confused?

SHM’s new, first-of-its-kind online educational tool can help.

CODE-H Interactive—short for “Coding Optimally for Documenting Effectively for Hospitalists”—gives hospitalists an online guided tour through six different coding scenarios, enabling them to choose the codes they believe are appropriate. Then, SHM’s coding expert highlights the correct codes and offers rationales for each.

HM groups can enroll multiple team members using a single subscription, making educating entire teams easy. Each participant receives a certificate documenting his or her participation in the program.

CODE-H Interactive is available today at www.hospitalmedicine.org/codehi.

Have you ever worried about which billing code is appropriate? Worried that your coding decisions could be called into question, but reading up on the topic only left you more confused?

SHM’s new, first-of-its-kind online educational tool can help.

CODE-H Interactive—short for “Coding Optimally for Documenting Effectively for Hospitalists”—gives hospitalists an online guided tour through six different coding scenarios, enabling them to choose the codes they believe are appropriate. Then, SHM’s coding expert highlights the correct codes and offers rationales for each.

HM groups can enroll multiple team members using a single subscription, making educating entire teams easy. Each participant receives a certificate documenting his or her participation in the program.

CODE-H Interactive is available today at www.hospitalmedicine.org/codehi.

Have you ever worried about which billing code is appropriate? Worried that your coding decisions could be called into question, but reading up on the topic only left you more confused?

SHM’s new, first-of-its-kind online educational tool can help.

CODE-H Interactive—short for “Coding Optimally for Documenting Effectively for Hospitalists”—gives hospitalists an online guided tour through six different coding scenarios, enabling them to choose the codes they believe are appropriate. Then, SHM’s coding expert highlights the correct codes and offers rationales for each.

HM groups can enroll multiple team members using a single subscription, making educating entire teams easy. Each participant receives a certificate documenting his or her participation in the program.

CODE-H Interactive is available today at www.hospitalmedicine.org/codehi.

Summary

Co-management is a growing area of pediatric HM involving both surgical and medical subspecialties. According to SHM, co-management is “shared responsibility, authority, and accountability for the care of a hospitalized patient across clinical specialties.”

Motivation for starting a co-management program may come from administrators concerned about quality, safety, or nursing; surgeons or subspecialists driven by time or knowledge constraints; or hospitalists looking to enhance patient safety, clinical skills, and practice development.

Pitfalls for hospitalists include patient “dumping,” care fragmentation, and working outside their scope of practice.

SHM identifies five keys to success for hospitalist co-management programs:

1. Identify obstacles and challenges, including the program’s stakeholders, goals, risks, and assumptions.
2. Clarify roles and responsibilities for areas such as admission and discharge, communication, documentation, and delineation of responsibilities. These should be specified in a service agreement.
3. Identify champions, ideally to include a surgeon or subspecialist, hospitalist, and administrator, as well as input from a family advisory council.
4. Measure performance in areas such as length of stay, resource utilization, quality, and safety metrics.
5. Address financial issues. Most programs require some financial support to supplement billing revenue.

Summary

Co-management is a growing area of pediatric HM involving both surgical and medical subspecialties. According to SHM, co-management is “shared responsibility, authority, and accountability for the care of a hospitalized patient across clinical specialties.”

Motivation for starting a co-management program may come from administrators concerned about quality, safety, or nursing; surgeons or subspecialists driven by time or knowledge constraints; or hospitalists looking to enhance patient safety, clinical skills, and practice development.

Pitfalls for hospitalists include patient “dumping,” care fragmentation, and working outside their scope of practice.

SHM identifies five keys to success for hospitalist co-management programs:

1. Identify obstacles and challenges, including the program’s stakeholders, goals, risks, and assumptions.
2. Clarify roles and responsibilities for areas such as admission and discharge, communication, documentation, and delineation of responsibilities. These should be specified in a service agreement.
3. Identify champions, ideally to include a surgeon or subspecialist, hospitalist, and administrator, as well as input from a family advisory council.
4. Measure performance in areas such as length of stay, resource utilization, quality, and safety metrics.
5. Address financial issues. Most programs require some financial support to supplement billing revenue.

Summary

Co-management is a growing area of pediatric HM involving both surgical and medical subspecialties. According to SHM, co-management is “shared responsibility, authority, and accountability for the care of a hospitalized patient across clinical specialties.”

Motivation for starting a co-management program may come from administrators concerned about quality, safety, or nursing; surgeons or subspecialists driven by time or knowledge constraints; or hospitalists looking to enhance patient safety, clinical skills, and practice development.

Pitfalls for hospitalists include patient “dumping,” care fragmentation, and working outside their scope of practice.

SHM identifies five keys to success for hospitalist co-management programs:

1. Identify obstacles and challenges, including the program’s stakeholders, goals, risks, and assumptions.
2. Clarify roles and responsibilities for areas such as admission and discharge, communication, documentation, and delineation of responsibilities. These should be specified in a service agreement.
3. Identify champions, ideally to include a surgeon or subspecialist, hospitalist, and administrator, as well as input from a family advisory council.
4. Measure performance in areas such as length of stay, resource utilization, quality, and safety metrics.
5. Address financial issues. Most programs require some financial support to supplement billing revenue.

Summary

Behavioral emergencies occur when a patient is physically aggressive or potentially harmful to himself/herself or others. Although they may be rare, behavioral emergencies are high-risk situations, and untrained staff might be uncomfortable dealing with these events.

Patients with underlying psychiatric or developmental disorders, those who have ingested substances, or those who have a medication side effect are at the highest risk for becoming violent. Triggers for these events could be pain, hunger, isolation, change in routine, or even the hospital’s physical environment. Early warning signs for a behavioral emergency can include verbal threats, yelling, or silence. Physical signs may include pacing, crossed arms, furrowed brow, or throwing objects.

The first response to a potential behavioral emergency is to try to de-escalate the situation. Speak in a quiet, calm voice; back off and give personal space. Try to reduce a source of discomfort, and use distractions or rewards. If de-escalation is not successful and a patient becomes violent, the provider’s first role is to be safe: Get away and get help. Hospitals should have—or should develop—a violent patient response team, which may then physically restrain the patient. Medications can be used to treat medical issues but should not be used solely for chemical restraint.

Once a patient is safely restrained, a number of Joint Commission on Accreditation of Healthcare Organizations-mandated actions must occur. The legal guardian and attending of record must be notified. A debrief must occur regarding the events; this must be documented in the medical record. Finally, a strategy must be formulated to enable the patient to be safely removed from restraints as soon as it is safe.

The presenters demonstrated various personal safety techniques to escape from a violent patient, as well as the use of physical restraints. Participants engaged in a mock behavioral emergency to experience the chaos of these events.

Summary

Behavioral emergencies occur when a patient is physically aggressive or potentially harmful to himself/herself or others. Although they may be rare, behavioral emergencies are high-risk situations, and untrained staff might be uncomfortable dealing with these events.

Patients with underlying psychiatric or developmental disorders, those who have ingested substances, or those who have a medication side effect are at the highest risk for becoming violent. Triggers for these events could be pain, hunger, isolation, change in routine, or even the hospital’s physical environment. Early warning signs for a behavioral emergency can include verbal threats, yelling, or silence. Physical signs may include pacing, crossed arms, furrowed brow, or throwing objects.

The first response to a potential behavioral emergency is to try to de-escalate the situation. Speak in a quiet, calm voice; back off and give personal space. Try to reduce a source of discomfort, and use distractions or rewards. If de-escalation is not successful and a patient becomes violent, the provider’s first role is to be safe: Get away and get help. Hospitals should have—or should develop—a violent patient response team, which may then physically restrain the patient. Medications can be used to treat medical issues but should not be used solely for chemical restraint.

Once a patient is safely restrained, a number of Joint Commission on Accreditation of Healthcare Organizations-mandated actions must occur. The legal guardian and attending of record must be notified. A debrief must occur regarding the events; this must be documented in the medical record. Finally, a strategy must be formulated to enable the patient to be safely removed from restraints as soon as it is safe.

The presenters demonstrated various personal safety techniques to escape from a violent patient, as well as the use of physical restraints. Participants engaged in a mock behavioral emergency to experience the chaos of these events.

Summary

Behavioral emergencies occur when a patient is physically aggressive or potentially harmful to himself/herself or others. Although they may be rare, behavioral emergencies are high-risk situations, and untrained staff might be uncomfortable dealing with these events.

Patients with underlying psychiatric or developmental disorders, those who have ingested substances, or those who have a medication side effect are at the highest risk for becoming violent. Triggers for these events could be pain, hunger, isolation, change in routine, or even the hospital’s physical environment. Early warning signs for a behavioral emergency can include verbal threats, yelling, or silence. Physical signs may include pacing, crossed arms, furrowed brow, or throwing objects.

The first response to a potential behavioral emergency is to try to de-escalate the situation. Speak in a quiet, calm voice; back off and give personal space. Try to reduce a source of discomfort, and use distractions or rewards. If de-escalation is not successful and a patient becomes violent, the provider’s first role is to be safe: Get away and get help. Hospitals should have—or should develop—a violent patient response team, which may then physically restrain the patient. Medications can be used to treat medical issues but should not be used solely for chemical restraint.

Once a patient is safely restrained, a number of Joint Commission on Accreditation of Healthcare Organizations-mandated actions must occur. The legal guardian and attending of record must be notified. A debrief must occur regarding the events; this must be documented in the medical record. Finally, a strategy must be formulated to enable the patient to be safely removed from restraints as soon as it is safe.

The presenters demonstrated various personal safety techniques to escape from a violent patient, as well as the use of physical restraints. Participants engaged in a mock behavioral emergency to experience the chaos of these events.

Summary

“Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high quality and sustainable program,” says Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of pediatric hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals programs should review before starting and also, periodically, after they’ve been established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine was used as a starting point for program self-evaluation.

These “building blocks” include the following:

• Establish the rationale for the program and include all stakeholders;
• Determine financial expectations;
• Define scope of practice;
• Organize nursing and referral physician collaboration;
• Assess staffing and workload expectations;
• Establish referral base; and
• Ensure basic code and emergency preparedness.

Ongoing development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

• Communication and collaboration with other hospital departments (e.g. emergency, radiology, surgery);
• Newborn medicine care;
• Internal group clinical practice guidelines;
• Co-management of surgical or specialty patients;
• Transfers from other hospitals or continuing care from tertiary care centers;
• Pediatric code teams and rapid response teams;
• Advanced code and emergency preparedness and mock code training; and
• Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program.

The essentials of a successful distributed network of multiple hospitalist program sites were also described.

After assuring that the fundamentals are present at each site, transparency and institutional alignment are imperative.

Summary

“Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high quality and sustainable program,” says Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of pediatric hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals programs should review before starting and also, periodically, after they’ve been established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine was used as a starting point for program self-evaluation.

These “building blocks” include the following:

• Establish the rationale for the program and include all stakeholders;
• Determine financial expectations;
• Define scope of practice;
• Organize nursing and referral physician collaboration;
• Assess staffing and workload expectations;
• Establish referral base; and
• Ensure basic code and emergency preparedness.

Ongoing development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

• Communication and collaboration with other hospital departments (e.g. emergency, radiology, surgery);
• Newborn medicine care;
• Internal group clinical practice guidelines;
• Co-management of surgical or specialty patients;
• Transfers from other hospitals or continuing care from tertiary care centers;
• Pediatric code teams and rapid response teams;
• Advanced code and emergency preparedness and mock code training; and
• Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program.

The essentials of a successful distributed network of multiple hospitalist program sites were also described.

After assuring that the fundamentals are present at each site, transparency and institutional alignment are imperative.

Summary

“Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high quality and sustainable program,” says Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of pediatric hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals programs should review before starting and also, periodically, after they’ve been established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine was used as a starting point for program self-evaluation.

These “building blocks” include the following:

• Establish the rationale for the program and include all stakeholders;
• Determine financial expectations;
• Define scope of practice;
• Organize nursing and referral physician collaboration;
• Assess staffing and workload expectations;
• Establish referral base; and
• Ensure basic code and emergency preparedness.

Ongoing development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

• Communication and collaboration with other hospital departments (e.g. emergency, radiology, surgery);
• Newborn medicine care;
• Internal group clinical practice guidelines;
• Co-management of surgical or specialty patients;
• Transfers from other hospitals or continuing care from tertiary care centers;
• Pediatric code teams and rapid response teams;
• Advanced code and emergency preparedness and mock code training; and
• Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program.

The essentials of a successful distributed network of multiple hospitalist program sites were also described.

After assuring that the fundamentals are present at each site, transparency and institutional alignment are imperative.