Practice Economics

Just over 7 million Americans signed up for private health insurance plans through federal and state insurance marketplaces during the Affordable Care Act’s first open enrollment period, according to preliminary figures released by the White House April 1.

The number is a bit of a surprise since only 4.2 million individuals had signed up for health plans as of March 1. A last minute surge helped the administration meet enrollment projections that were made before the technical glitches plagued the start of healthcare.gov in October and November.

Complete enrollment numbers, as well information on how many people have actually paid their premiums, will not be available for a few more weeks, administration officials said.

In the meantime, President Obama pointed to the enrollment number as proof that the health care law is working. And he blasted opponents who have spent the last several months trying to repeal or undermine the law.

"I will always work with anyone who is willing to make this law work even better," President Obama said from the Rose Garden. "But the debate over repealing this law is over. The Affordable Care Act is here to stay."

[email protected]

On Twitter @maryellenny

Just over 7 million Americans signed up for private health insurance plans through federal and state insurance marketplaces during the Affordable Care Act’s first open enrollment period, according to preliminary figures released by the White House April 1.

The number is a bit of a surprise since only 4.2 million individuals had signed up for health plans as of March 1. A last minute surge helped the administration meet enrollment projections that were made before the technical glitches plagued the start of healthcare.gov in October and November.

Complete enrollment numbers, as well information on how many people have actually paid their premiums, will not be available for a few more weeks, administration officials said.

In the meantime, President Obama pointed to the enrollment number as proof that the health care law is working. And he blasted opponents who have spent the last several months trying to repeal or undermine the law.

"I will always work with anyone who is willing to make this law work even better," President Obama said from the Rose Garden. "But the debate over repealing this law is over. The Affordable Care Act is here to stay."

[email protected]

On Twitter @maryellenny

Just over 7 million Americans signed up for private health insurance plans through federal and state insurance marketplaces during the Affordable Care Act’s first open enrollment period, according to preliminary figures released by the White House April 1.

The number is a bit of a surprise since only 4.2 million individuals had signed up for health plans as of March 1. A last minute surge helped the administration meet enrollment projections that were made before the technical glitches plagued the start of healthcare.gov in October and November.

Complete enrollment numbers, as well information on how many people have actually paid their premiums, will not be available for a few more weeks, administration officials said.

In the meantime, President Obama pointed to the enrollment number as proof that the health care law is working. And he blasted opponents who have spent the last several months trying to repeal or undermine the law.

"I will always work with anyone who is willing to make this law work even better," President Obama said from the Rose Garden. "But the debate over repealing this law is over. The Affordable Care Act is here to stay."

[email protected]

On Twitter @maryellenny

Postpartum Shortness of Breath

A 35-year-old woman presented to the ED after referral by her obstetrician. Six days prior, the patient had given birth to twins without incident. On postpartum hospital day 2, however, she developed mild shortness of breath, and a chest X-ray was ordered. Since there was concern for possible pneumonia, the patient was prescribed oral antibiotics and discharged home on hospital day 4. She continued to complain of shortness of breath following discharge; at that time, the obstetrician referred the patient to the ED for further evaluation.

The patient was evaluated by the EP, who ordered a chest X-ray. He was also concerned that patient had pneumonia and prescribed a different class of antibiotic before discharging the patient home.

One week later, the patient presented back to the same ED with continued shortness of breath. On this visit, she was seen by a physician assistant (PA). Following the history taking and physical examination, a chest X-ray and rapid flu and rapid strep tests were ordered. Both the PA and supervising EP reviewed the chest X-ray and were concerned for pneumonia; however, both the flu and strep tests were negative. A third class of antibiotic was prescribed, and the patient was discharged home.

The chest X-ray on the second ED visit was not interpreted by a radiologist until 3 days later (The patient was seen on a Friday evening and the films were not read until the following Monday morning). The radiologist’s interpretation was “worsening congestive heart failure” (CHF). Two days later (5 days following the second ED visit), the EP was notified of the interpretation discrepancy and made multiple attempts to contact the patient, which included leaving a voice-mail message on her home phone.

The patient returned the call the following day and spoke with one of the ED nurses, who encouraged her to return immediately to the ED. The patient returned to the ED the next day (1 week after her second ED visit) and was admitted to the hospital for CHF secondary to postpartum cardiomyopathy. Unfortunately, she developed an embolus to her kidney, followed by an ischemic cerebrovascular accident, and died 3 weeks after admission.

The patient’s family filed a malpractice lawsuit against the hospital, the EPs, and the PA for negligent delay in making the correct diagnosis, stating that patient’s subsequent stroke and death were a direct result of this delay. Following deliberations, all of the EPs involved in the case were found free of negligence; the PA and the hospital ED, however, were found guilty.

Discussion

Interestingly, the majority of successful malpractice suits against physicians involve cognitive errors and system issues; this case is no exception. Making the correct diagnosis in a patient is a complex process, involving data gathering and synthesis, intuition, clinical experience, and logical thinking. Unfortunately, biases can occur during this process and result in misdiagnosis or delayed diagnosis. These biases include anchoring bias, confirmation bias, premature closure, and diagnosis momentum.¹

Anchoring Bias. This occurs when a physician relies too heavily on the first piece of information or one’s initial impression.¹ Despite evidence to the contrary, the physician keeps returning to the initial diagnosis (ie, he or she is “anchored” to it).

Confirmation Bias. Related to anchoring bias, in confirmation bias, the physician ignores or discounts evidence that contradicts one’s initial impression and focuses solely on the evidence supporting it.¹

Both anchoring bias and confirmation bias appear to have played a role in this case. The differential diagnosis was never broadened beyond pneumonia, despite the fact that one must also consider pulmonary embolism (ie, a hypercoagulable state) and CHF (ie, postpartum cardiomyopathy) in a patient complaining of dyspnea in the postpartum period.

Premature Closure. This occurs when the physician finds a cause that fits the clinical picture and ceases to search for other diagnostic possibilities.^1,2

Diagnosis Momentum. A bias that occurs when the diagnosis considered a possibility by one physician becomes a definitive diagnosis as it is passed from one physician to the next; it then becomes accepted without question by physicians down the line.¹ This type of bias also seems to have played a role in this case.

There are a few strategies to help prevent or minimize these types of errors. First, as new data are gathered, one should reconsider and reprioritize the differential diagnosis. When certain data points do not fit neatly with an earlier diagnosis, careful attention must be paid to them. This is especially true for the patient receiving appropriate treatment but not showing clinical improvement. While it is usually helpful to know previous working diagnoses, the clinician must try to keep an open mind and consider alternative diagnoses. At the end of the day, the lesson is the need to develop a broad differential diagnosis.²

The system error in this case involves the lack of timely overread of radiology studies. Emergency medicine is a 24-hour, 7-day-a-week specialty; therefore, support services to the ED need to be similarly available. With today’s teleradiology and dedicated night readers, it is difficult to justify not providing such a service. This situation explains, in part, the negligent verdict against the hospital.

Chest Pain in a Man With Type 2 Diabetes

A 54-year-old man presented to the ED with a several-hour history of chest pain and shortness of breath. His medical history was remarkable for type 2 diabetes mellitus. He denied any associated nausea, vomiting, or diaphoresis. He smoked one pack of cigarettes per day and drank alcohol on occasion. The patient further denied having experienced similar symptoms in the past. All vital signs were normal, and he appeared comfortable and in no acute distress. His physical examination was completely unremarkable.

An electrocardiogram (ECG) revealed Q-waves in the anterior leads, but was otherwise nondiagnostic. The results of a portable chest X-ray were interpreted as normal. Cardiac enzyme testing revealed a positive troponin I, but a normal creatine phosphokinase-MB (CPK-MB). The patient’s complete blood count and coagulation studies were normal, and a basic metabolic profile was remarkable only for a blood sugar of 540 mg/dL; his serum bicarbonate value was normal.

The patient was placed on oxygen via nasal cannula, administered an aspirin (325 mg), and given subcutaneous regular insulin for hyperglycemia. The EP contacted a hospitalist to admit the patient. The hospitalist accepted the patient and admitted him to the telemetry floor.

Upon arrival at telemetry, the patient was examined by a nurse who noted rhonchi bilaterally on lung auscultation. Shortly afterward, he became anxious, and the nurse consulted the hospitalist, who ordered administration of lorazepam. Approximately 20 minutes later, the patient went into cardiac arrest and died.

This patient was never examined by the hospitalist prior to coding. An autopsy revealed evidence of severe coronary artery disease, a previous infarction that was at least a few months old with scarring of the left ventricle, and a recent infarction that had begun at least 12 hours prior to death.

The family sued all of the providers involved in the care of the patient. At trial, there was a factual dispute regarding whether the EP informed the hospitalist of the elevated troponin I level. The defendants argued that the patient had sustained irreversible heart damage prior to his arrival at the hospital, and that nothing any of the defendants could have done would have saved his life. The jury deliberated for approximately 2 hours before delivering a verdict in favor of the defense.

Discussion

Clearly, this verdict could have gone the other way. This patient was experiencing a non-ST segment elevation myocardial infarction (MI). The nondiagnostic ECG, coupled with the elevated troponin I, indicated damage of heart muscle from an acute interruption of coronary blood flow.

There are several problems with the management of this case. First, this patient required a cardiology consult for risk stratification. Several scoring systems could have been used to determine whether this patient was a candidate for early (ie, within 4-48 hours) invasive treatments such as percutaneous intervention or a more conservative approach.

Second, having sustained an MI, this patient was at high risk for complications such as ventricular arrhythmias, heart failure, cardiogenic shock, and other serious adverse events. Patients with acute MI should be admitted to the critical care or intensive care unit. In addition to aspirin, this patient should have received nitroglycerin and anticoagulation therapy. Either heparin or a low molecular weight heparin, such as enoxaparin, would have been appropriate if no contraindications existed. Finally, additional therapy including glycoprotein IIB/IIIA inhibitors, clopidogrel, etc, may have been indicated depending upon the timing of percutaneous intervention.¹

It appears that both the EP and the hospitalist either failed to appreciate the significance of the elevated troponin I or overlooked it. This patient had normal renal function, so the only explanation—especially in the setting of a middle-aged man complaining of chest pain—was that myocardial damage had occurred.

Alcohol Detoxification in a Young Man

A young man was brought to the ED by a friend. The patient’s sole complaint was the need for help with his alcohol dependency. In addition to alcohol abuse, his medical history was remarkable only for an admission 1 month prior for suicidal ideation. The patient denied suicidal or homicidal ideations on this presentation. The physical examination revealed stable vital signs, but conjunctival injection, slurred speech, and a strong odor of alcohol. A blood alcohol test showed a concentration level of 0.36 g/dL. The patient, however, was alert and able to ambulate without assistance. He was medically cleared by the EP and arrangements were made to admit him to a local detoxification center.

Approximately 4 hours after his arrival, while waiting for transport to the detoxification center, the patient became impatient with the delay, removed his intravenous line, and told the nurse that he was going home via taxi. The nurse encouraged him to call a friend to take him home, to which to the patient agreed. The nurse left the patient to inform the EP of his desire to go home; when she returned, she discovered that the patient had already left the hospital. The physician notified hospital security but not the police. Approximately 2 hours later, the patient was struck by a car and seriously injured.

The patient sued the EP and the hospital for negligence and medical malpractice. The suit alleged that the physician and the hospital should have prevented the patient from leaving the ED. The physician and the hospital requested a dismissal, arguing that the patient did not exhibit any suicidal or homicidal ideation, presented on his own volition, and, though intoxicated, could still make decisions for himself. An appellate court granted the motion, holding that the defendants “lacked authority to confine the plaintiff upon his departure” from the ED.

Discussion

When a patient attempts to leave the ED against medical advice, the treating physician should make an attempt to convince him or her to remain for treatment. Often, something as simple as offering a cup of coffee will change a patient’s mind. In other instances, the use of chemical or physical restraint may be required. The handling of the case ultimately becomes a question of whether the patient was competent to make decisions and whether he presented a danger to himself or others. The extent of intoxication varies by the degree and does not of itself constitute incapability to make decisions. All practicing EPs have cared for patients with blood alcohol levels above the legal limit for driving, but who were functionally sober and able to make decisions. If a patient is competent and does not present a danger to self or others, he or she can decide to leave the ED without further management. However, it is best to release the patient in the company of friends or family, as was urged by the nurse in this case. Obviously, such a patient should not be allowed to drive himself home.

When a patient does leave against medical advice, the physician and nurse should document in the ED record their conversations urging him or her to stay. Alternatively, when a patient is found incompetent of making decisions or is a danger to self or others, he or she must be prevented from leaving the ED. This includes use of the minimal amount of physical or chemical restraint needed to keep the patient from leaving. When there is doubt that the patient is able to make a competent decision, it is better to err on the side of caution and keep him or her in the ED for his own safety and the safety of others.

Postpartum Shortness of Breath

A 35-year-old woman presented to the ED after referral by her obstetrician. Six days prior, the patient had given birth to twins without incident. On postpartum hospital day 2, however, she developed mild shortness of breath, and a chest X-ray was ordered. Since there was concern for possible pneumonia, the patient was prescribed oral antibiotics and discharged home on hospital day 4. She continued to complain of shortness of breath following discharge; at that time, the obstetrician referred the patient to the ED for further evaluation.

The patient was evaluated by the EP, who ordered a chest X-ray. He was also concerned that patient had pneumonia and prescribed a different class of antibiotic before discharging the patient home.

One week later, the patient presented back to the same ED with continued shortness of breath. On this visit, she was seen by a physician assistant (PA). Following the history taking and physical examination, a chest X-ray and rapid flu and rapid strep tests were ordered. Both the PA and supervising EP reviewed the chest X-ray and were concerned for pneumonia; however, both the flu and strep tests were negative. A third class of antibiotic was prescribed, and the patient was discharged home.

The chest X-ray on the second ED visit was not interpreted by a radiologist until 3 days later (The patient was seen on a Friday evening and the films were not read until the following Monday morning). The radiologist’s interpretation was “worsening congestive heart failure” (CHF). Two days later (5 days following the second ED visit), the EP was notified of the interpretation discrepancy and made multiple attempts to contact the patient, which included leaving a voice-mail message on her home phone.

The patient returned the call the following day and spoke with one of the ED nurses, who encouraged her to return immediately to the ED. The patient returned to the ED the next day (1 week after her second ED visit) and was admitted to the hospital for CHF secondary to postpartum cardiomyopathy. Unfortunately, she developed an embolus to her kidney, followed by an ischemic cerebrovascular accident, and died 3 weeks after admission.

The patient’s family filed a malpractice lawsuit against the hospital, the EPs, and the PA for negligent delay in making the correct diagnosis, stating that patient’s subsequent stroke and death were a direct result of this delay. Following deliberations, all of the EPs involved in the case were found free of negligence; the PA and the hospital ED, however, were found guilty.

Discussion

Interestingly, the majority of successful malpractice suits against physicians involve cognitive errors and system issues; this case is no exception. Making the correct diagnosis in a patient is a complex process, involving data gathering and synthesis, intuition, clinical experience, and logical thinking. Unfortunately, biases can occur during this process and result in misdiagnosis or delayed diagnosis. These biases include anchoring bias, confirmation bias, premature closure, and diagnosis momentum.¹

Anchoring Bias. This occurs when a physician relies too heavily on the first piece of information or one’s initial impression.¹ Despite evidence to the contrary, the physician keeps returning to the initial diagnosis (ie, he or she is “anchored” to it).

Confirmation Bias. Related to anchoring bias, in confirmation bias, the physician ignores or discounts evidence that contradicts one’s initial impression and focuses solely on the evidence supporting it.¹

Both anchoring bias and confirmation bias appear to have played a role in this case. The differential diagnosis was never broadened beyond pneumonia, despite the fact that one must also consider pulmonary embolism (ie, a hypercoagulable state) and CHF (ie, postpartum cardiomyopathy) in a patient complaining of dyspnea in the postpartum period.

Premature Closure. This occurs when the physician finds a cause that fits the clinical picture and ceases to search for other diagnostic possibilities.^1,2

Diagnosis Momentum. A bias that occurs when the diagnosis considered a possibility by one physician becomes a definitive diagnosis as it is passed from one physician to the next; it then becomes accepted without question by physicians down the line.¹ This type of bias also seems to have played a role in this case.

There are a few strategies to help prevent or minimize these types of errors. First, as new data are gathered, one should reconsider and reprioritize the differential diagnosis. When certain data points do not fit neatly with an earlier diagnosis, careful attention must be paid to them. This is especially true for the patient receiving appropriate treatment but not showing clinical improvement. While it is usually helpful to know previous working diagnoses, the clinician must try to keep an open mind and consider alternative diagnoses. At the end of the day, the lesson is the need to develop a broad differential diagnosis.²

The system error in this case involves the lack of timely overread of radiology studies. Emergency medicine is a 24-hour, 7-day-a-week specialty; therefore, support services to the ED need to be similarly available. With today’s teleradiology and dedicated night readers, it is difficult to justify not providing such a service. This situation explains, in part, the negligent verdict against the hospital.

Chest Pain in a Man With Type 2 Diabetes

A 54-year-old man presented to the ED with a several-hour history of chest pain and shortness of breath. His medical history was remarkable for type 2 diabetes mellitus. He denied any associated nausea, vomiting, or diaphoresis. He smoked one pack of cigarettes per day and drank alcohol on occasion. The patient further denied having experienced similar symptoms in the past. All vital signs were normal, and he appeared comfortable and in no acute distress. His physical examination was completely unremarkable.

An electrocardiogram (ECG) revealed Q-waves in the anterior leads, but was otherwise nondiagnostic. The results of a portable chest X-ray were interpreted as normal. Cardiac enzyme testing revealed a positive troponin I, but a normal creatine phosphokinase-MB (CPK-MB). The patient’s complete blood count and coagulation studies were normal, and a basic metabolic profile was remarkable only for a blood sugar of 540 mg/dL; his serum bicarbonate value was normal.

The patient was placed on oxygen via nasal cannula, administered an aspirin (325 mg), and given subcutaneous regular insulin for hyperglycemia. The EP contacted a hospitalist to admit the patient. The hospitalist accepted the patient and admitted him to the telemetry floor.

Upon arrival at telemetry, the patient was examined by a nurse who noted rhonchi bilaterally on lung auscultation. Shortly afterward, he became anxious, and the nurse consulted the hospitalist, who ordered administration of lorazepam. Approximately 20 minutes later, the patient went into cardiac arrest and died.

This patient was never examined by the hospitalist prior to coding. An autopsy revealed evidence of severe coronary artery disease, a previous infarction that was at least a few months old with scarring of the left ventricle, and a recent infarction that had begun at least 12 hours prior to death.

The family sued all of the providers involved in the care of the patient. At trial, there was a factual dispute regarding whether the EP informed the hospitalist of the elevated troponin I level. The defendants argued that the patient had sustained irreversible heart damage prior to his arrival at the hospital, and that nothing any of the defendants could have done would have saved his life. The jury deliberated for approximately 2 hours before delivering a verdict in favor of the defense.

Discussion

Clearly, this verdict could have gone the other way. This patient was experiencing a non-ST segment elevation myocardial infarction (MI). The nondiagnostic ECG, coupled with the elevated troponin I, indicated damage of heart muscle from an acute interruption of coronary blood flow.

There are several problems with the management of this case. First, this patient required a cardiology consult for risk stratification. Several scoring systems could have been used to determine whether this patient was a candidate for early (ie, within 4-48 hours) invasive treatments such as percutaneous intervention or a more conservative approach.

Second, having sustained an MI, this patient was at high risk for complications such as ventricular arrhythmias, heart failure, cardiogenic shock, and other serious adverse events. Patients with acute MI should be admitted to the critical care or intensive care unit. In addition to aspirin, this patient should have received nitroglycerin and anticoagulation therapy. Either heparin or a low molecular weight heparin, such as enoxaparin, would have been appropriate if no contraindications existed. Finally, additional therapy including glycoprotein IIB/IIIA inhibitors, clopidogrel, etc, may have been indicated depending upon the timing of percutaneous intervention.¹

It appears that both the EP and the hospitalist either failed to appreciate the significance of the elevated troponin I or overlooked it. This patient had normal renal function, so the only explanation—especially in the setting of a middle-aged man complaining of chest pain—was that myocardial damage had occurred.

Alcohol Detoxification in a Young Man

A young man was brought to the ED by a friend. The patient’s sole complaint was the need for help with his alcohol dependency. In addition to alcohol abuse, his medical history was remarkable only for an admission 1 month prior for suicidal ideation. The patient denied suicidal or homicidal ideations on this presentation. The physical examination revealed stable vital signs, but conjunctival injection, slurred speech, and a strong odor of alcohol. A blood alcohol test showed a concentration level of 0.36 g/dL. The patient, however, was alert and able to ambulate without assistance. He was medically cleared by the EP and arrangements were made to admit him to a local detoxification center.

Approximately 4 hours after his arrival, while waiting for transport to the detoxification center, the patient became impatient with the delay, removed his intravenous line, and told the nurse that he was going home via taxi. The nurse encouraged him to call a friend to take him home, to which to the patient agreed. The nurse left the patient to inform the EP of his desire to go home; when she returned, she discovered that the patient had already left the hospital. The physician notified hospital security but not the police. Approximately 2 hours later, the patient was struck by a car and seriously injured.

The patient sued the EP and the hospital for negligence and medical malpractice. The suit alleged that the physician and the hospital should have prevented the patient from leaving the ED. The physician and the hospital requested a dismissal, arguing that the patient did not exhibit any suicidal or homicidal ideation, presented on his own volition, and, though intoxicated, could still make decisions for himself. An appellate court granted the motion, holding that the defendants “lacked authority to confine the plaintiff upon his departure” from the ED.

Discussion

When a patient attempts to leave the ED against medical advice, the treating physician should make an attempt to convince him or her to remain for treatment. Often, something as simple as offering a cup of coffee will change a patient’s mind. In other instances, the use of chemical or physical restraint may be required. The handling of the case ultimately becomes a question of whether the patient was competent to make decisions and whether he presented a danger to himself or others. The extent of intoxication varies by the degree and does not of itself constitute incapability to make decisions. All practicing EPs have cared for patients with blood alcohol levels above the legal limit for driving, but who were functionally sober and able to make decisions. If a patient is competent and does not present a danger to self or others, he or she can decide to leave the ED without further management. However, it is best to release the patient in the company of friends or family, as was urged by the nurse in this case. Obviously, such a patient should not be allowed to drive himself home.

When a patient does leave against medical advice, the physician and nurse should document in the ED record their conversations urging him or her to stay. Alternatively, when a patient is found incompetent of making decisions or is a danger to self or others, he or she must be prevented from leaving the ED. This includes use of the minimal amount of physical or chemical restraint needed to keep the patient from leaving. When there is doubt that the patient is able to make a competent decision, it is better to err on the side of caution and keep him or her in the ED for his own safety and the safety of others.

Postpartum Shortness of Breath

A 35-year-old woman presented to the ED after referral by her obstetrician. Six days prior, the patient had given birth to twins without incident. On postpartum hospital day 2, however, she developed mild shortness of breath, and a chest X-ray was ordered. Since there was concern for possible pneumonia, the patient was prescribed oral antibiotics and discharged home on hospital day 4. She continued to complain of shortness of breath following discharge; at that time, the obstetrician referred the patient to the ED for further evaluation.

The patient was evaluated by the EP, who ordered a chest X-ray. He was also concerned that patient had pneumonia and prescribed a different class of antibiotic before discharging the patient home.

One week later, the patient presented back to the same ED with continued shortness of breath. On this visit, she was seen by a physician assistant (PA). Following the history taking and physical examination, a chest X-ray and rapid flu and rapid strep tests were ordered. Both the PA and supervising EP reviewed the chest X-ray and were concerned for pneumonia; however, both the flu and strep tests were negative. A third class of antibiotic was prescribed, and the patient was discharged home.

The chest X-ray on the second ED visit was not interpreted by a radiologist until 3 days later (The patient was seen on a Friday evening and the films were not read until the following Monday morning). The radiologist’s interpretation was “worsening congestive heart failure” (CHF). Two days later (5 days following the second ED visit), the EP was notified of the interpretation discrepancy and made multiple attempts to contact the patient, which included leaving a voice-mail message on her home phone.

The patient returned the call the following day and spoke with one of the ED nurses, who encouraged her to return immediately to the ED. The patient returned to the ED the next day (1 week after her second ED visit) and was admitted to the hospital for CHF secondary to postpartum cardiomyopathy. Unfortunately, she developed an embolus to her kidney, followed by an ischemic cerebrovascular accident, and died 3 weeks after admission.

The patient’s family filed a malpractice lawsuit against the hospital, the EPs, and the PA for negligent delay in making the correct diagnosis, stating that patient’s subsequent stroke and death were a direct result of this delay. Following deliberations, all of the EPs involved in the case were found free of negligence; the PA and the hospital ED, however, were found guilty.

Discussion

Interestingly, the majority of successful malpractice suits against physicians involve cognitive errors and system issues; this case is no exception. Making the correct diagnosis in a patient is a complex process, involving data gathering and synthesis, intuition, clinical experience, and logical thinking. Unfortunately, biases can occur during this process and result in misdiagnosis or delayed diagnosis. These biases include anchoring bias, confirmation bias, premature closure, and diagnosis momentum.¹

Anchoring Bias. This occurs when a physician relies too heavily on the first piece of information or one’s initial impression.¹ Despite evidence to the contrary, the physician keeps returning to the initial diagnosis (ie, he or she is “anchored” to it).

Confirmation Bias. Related to anchoring bias, in confirmation bias, the physician ignores or discounts evidence that contradicts one’s initial impression and focuses solely on the evidence supporting it.¹

Both anchoring bias and confirmation bias appear to have played a role in this case. The differential diagnosis was never broadened beyond pneumonia, despite the fact that one must also consider pulmonary embolism (ie, a hypercoagulable state) and CHF (ie, postpartum cardiomyopathy) in a patient complaining of dyspnea in the postpartum period.

Premature Closure. This occurs when the physician finds a cause that fits the clinical picture and ceases to search for other diagnostic possibilities.^1,2

Diagnosis Momentum. A bias that occurs when the diagnosis considered a possibility by one physician becomes a definitive diagnosis as it is passed from one physician to the next; it then becomes accepted without question by physicians down the line.¹ This type of bias also seems to have played a role in this case.

There are a few strategies to help prevent or minimize these types of errors. First, as new data are gathered, one should reconsider and reprioritize the differential diagnosis. When certain data points do not fit neatly with an earlier diagnosis, careful attention must be paid to them. This is especially true for the patient receiving appropriate treatment but not showing clinical improvement. While it is usually helpful to know previous working diagnoses, the clinician must try to keep an open mind and consider alternative diagnoses. At the end of the day, the lesson is the need to develop a broad differential diagnosis.²

The system error in this case involves the lack of timely overread of radiology studies. Emergency medicine is a 24-hour, 7-day-a-week specialty; therefore, support services to the ED need to be similarly available. With today’s teleradiology and dedicated night readers, it is difficult to justify not providing such a service. This situation explains, in part, the negligent verdict against the hospital.

Chest Pain in a Man With Type 2 Diabetes

A 54-year-old man presented to the ED with a several-hour history of chest pain and shortness of breath. His medical history was remarkable for type 2 diabetes mellitus. He denied any associated nausea, vomiting, or diaphoresis. He smoked one pack of cigarettes per day and drank alcohol on occasion. The patient further denied having experienced similar symptoms in the past. All vital signs were normal, and he appeared comfortable and in no acute distress. His physical examination was completely unremarkable.

An electrocardiogram (ECG) revealed Q-waves in the anterior leads, but was otherwise nondiagnostic. The results of a portable chest X-ray were interpreted as normal. Cardiac enzyme testing revealed a positive troponin I, but a normal creatine phosphokinase-MB (CPK-MB). The patient’s complete blood count and coagulation studies were normal, and a basic metabolic profile was remarkable only for a blood sugar of 540 mg/dL; his serum bicarbonate value was normal.

The patient was placed on oxygen via nasal cannula, administered an aspirin (325 mg), and given subcutaneous regular insulin for hyperglycemia. The EP contacted a hospitalist to admit the patient. The hospitalist accepted the patient and admitted him to the telemetry floor.

Upon arrival at telemetry, the patient was examined by a nurse who noted rhonchi bilaterally on lung auscultation. Shortly afterward, he became anxious, and the nurse consulted the hospitalist, who ordered administration of lorazepam. Approximately 20 minutes later, the patient went into cardiac arrest and died.

This patient was never examined by the hospitalist prior to coding. An autopsy revealed evidence of severe coronary artery disease, a previous infarction that was at least a few months old with scarring of the left ventricle, and a recent infarction that had begun at least 12 hours prior to death.

The family sued all of the providers involved in the care of the patient. At trial, there was a factual dispute regarding whether the EP informed the hospitalist of the elevated troponin I level. The defendants argued that the patient had sustained irreversible heart damage prior to his arrival at the hospital, and that nothing any of the defendants could have done would have saved his life. The jury deliberated for approximately 2 hours before delivering a verdict in favor of the defense.

Discussion

Clearly, this verdict could have gone the other way. This patient was experiencing a non-ST segment elevation myocardial infarction (MI). The nondiagnostic ECG, coupled with the elevated troponin I, indicated damage of heart muscle from an acute interruption of coronary blood flow.

There are several problems with the management of this case. First, this patient required a cardiology consult for risk stratification. Several scoring systems could have been used to determine whether this patient was a candidate for early (ie, within 4-48 hours) invasive treatments such as percutaneous intervention or a more conservative approach.

Second, having sustained an MI, this patient was at high risk for complications such as ventricular arrhythmias, heart failure, cardiogenic shock, and other serious adverse events. Patients with acute MI should be admitted to the critical care or intensive care unit. In addition to aspirin, this patient should have received nitroglycerin and anticoagulation therapy. Either heparin or a low molecular weight heparin, such as enoxaparin, would have been appropriate if no contraindications existed. Finally, additional therapy including glycoprotein IIB/IIIA inhibitors, clopidogrel, etc, may have been indicated depending upon the timing of percutaneous intervention.¹

It appears that both the EP and the hospitalist either failed to appreciate the significance of the elevated troponin I or overlooked it. This patient had normal renal function, so the only explanation—especially in the setting of a middle-aged man complaining of chest pain—was that myocardial damage had occurred.

Alcohol Detoxification in a Young Man

A young man was brought to the ED by a friend. The patient’s sole complaint was the need for help with his alcohol dependency. In addition to alcohol abuse, his medical history was remarkable only for an admission 1 month prior for suicidal ideation. The patient denied suicidal or homicidal ideations on this presentation. The physical examination revealed stable vital signs, but conjunctival injection, slurred speech, and a strong odor of alcohol. A blood alcohol test showed a concentration level of 0.36 g/dL. The patient, however, was alert and able to ambulate without assistance. He was medically cleared by the EP and arrangements were made to admit him to a local detoxification center.

Approximately 4 hours after his arrival, while waiting for transport to the detoxification center, the patient became impatient with the delay, removed his intravenous line, and told the nurse that he was going home via taxi. The nurse encouraged him to call a friend to take him home, to which to the patient agreed. The nurse left the patient to inform the EP of his desire to go home; when she returned, she discovered that the patient had already left the hospital. The physician notified hospital security but not the police. Approximately 2 hours later, the patient was struck by a car and seriously injured.

The patient sued the EP and the hospital for negligence and medical malpractice. The suit alleged that the physician and the hospital should have prevented the patient from leaving the ED. The physician and the hospital requested a dismissal, arguing that the patient did not exhibit any suicidal or homicidal ideation, presented on his own volition, and, though intoxicated, could still make decisions for himself. An appellate court granted the motion, holding that the defendants “lacked authority to confine the plaintiff upon his departure” from the ED.

Discussion

When a patient attempts to leave the ED against medical advice, the treating physician should make an attempt to convince him or her to remain for treatment. Often, something as simple as offering a cup of coffee will change a patient’s mind. In other instances, the use of chemical or physical restraint may be required. The handling of the case ultimately becomes a question of whether the patient was competent to make decisions and whether he presented a danger to himself or others. The extent of intoxication varies by the degree and does not of itself constitute incapability to make decisions. All practicing EPs have cared for patients with blood alcohol levels above the legal limit for driving, but who were functionally sober and able to make decisions. If a patient is competent and does not present a danger to self or others, he or she can decide to leave the ED without further management. However, it is best to release the patient in the company of friends or family, as was urged by the nurse in this case. Obviously, such a patient should not be allowed to drive himself home.

When a patient does leave against medical advice, the physician and nurse should document in the ED record their conversations urging him or her to stay. Alternatively, when a patient is found incompetent of making decisions or is a danger to self or others, he or she must be prevented from leaving the ED. This includes use of the minimal amount of physical or chemical restraint needed to keep the patient from leaving. When there is doubt that the patient is able to make a competent decision, it is better to err on the side of caution and keep him or her in the ED for his own safety and the safety of others.

In a last-minute move, Congress averted a scheduled 24% cut to Medicare physician fees slated to start on April 1, while simultaneously delaying the move to the ICD-10 coding sets.

On March 31, the Senate voted 64 to 35 to approve H.R. 4302, a bill that replaces the scheduled cut called for by the Medicare Sustainable Growth Rate formula with a 0.5% fee increase through the end of 2014 and a pay freeze from Jan. 1, 2015 through March 15, 2015. The bill also bars the Health and Human Services (HHS) department from implementing ICD-10 until Oct. 1, 2015.

Alicia Ault/Frontline Medical News

The House passed the same legislation on March 27. It now heads to the White House for President Obama’s signature.

At first glance, the bill looks like good news for physicians, who will get relief from both a hefty Medicare fee cut and a costly new regulatory requirement. But many physician organizations, led by the American Medical Association, have campaigned against the temporary patch, saying that it essentially stops the work to permanently repeal the SGR.

"It appears that an unprecedented, bipartisan agreement on Medicare reform is on the verge of being cast aside because elected leaders are unwilling to make tough choices to strengthen programs serving 50 million Americans," the AMA and more than 50 other medical societies wrote to congressional leaders before the House vote.

Several physician groups had endorsed a bipartisan legislative package that would have eliminated the SGR and replaced it with a combination of small fee increases and delivery system reforms. The hurdle to passing the legislation was finding a way to pay for it that would appeal to both Democrats and Republicans.

Recently, the House passed H.R. 4015, which would have funded the permanent SGR repeal package with a 5-year delay of the Affordable Care Act’s individual insurance mandate. But that bill is unlikely to be considered in the Democratic-controlled Senate. And an attempt by Sen. Ron Wyden (D.-Ore.) to move the permanent SGR repeal forward and pay for it using the savings from the end of the wars in Iraq and Afghanistan failed to gain enough votes in the Senate.

Before the March 31 vote, Sen. Wyden chided fellow lawmakers for continuing to pass temporary fixes to the SGR problem rather than replacing it and moving to a payment system that incentivizes quality improvement. "It can’t be ducked much longer," he said.

But Sen. Orrin Hatch (R.-Utah), who worked on the bipartisan bill to replace the SGR, said he objects to the funding mechanism that Sen. Wyden proposed. He said the 12-month SGR patch will give lawmakers more time to agree on how to pay for a permanent fix. "I’m not going to make the perfect the enemy of the good," he said on the Senate floor.

[email protected]

On Twitter @maryellenny

In a last-minute move, Congress averted a scheduled 24% cut to Medicare physician fees slated to start on April 1, while simultaneously delaying the move to the ICD-10 coding sets.

On March 31, the Senate voted 64 to 35 to approve H.R. 4302, a bill that replaces the scheduled cut called for by the Medicare Sustainable Growth Rate formula with a 0.5% fee increase through the end of 2014 and a pay freeze from Jan. 1, 2015 through March 15, 2015. The bill also bars the Health and Human Services (HHS) department from implementing ICD-10 until Oct. 1, 2015.

Alicia Ault/Frontline Medical News

The House passed the same legislation on March 27. It now heads to the White House for President Obama’s signature.

At first glance, the bill looks like good news for physicians, who will get relief from both a hefty Medicare fee cut and a costly new regulatory requirement. But many physician organizations, led by the American Medical Association, have campaigned against the temporary patch, saying that it essentially stops the work to permanently repeal the SGR.

"It appears that an unprecedented, bipartisan agreement on Medicare reform is on the verge of being cast aside because elected leaders are unwilling to make tough choices to strengthen programs serving 50 million Americans," the AMA and more than 50 other medical societies wrote to congressional leaders before the House vote.

Several physician groups had endorsed a bipartisan legislative package that would have eliminated the SGR and replaced it with a combination of small fee increases and delivery system reforms. The hurdle to passing the legislation was finding a way to pay for it that would appeal to both Democrats and Republicans.

Recently, the House passed H.R. 4015, which would have funded the permanent SGR repeal package with a 5-year delay of the Affordable Care Act’s individual insurance mandate. But that bill is unlikely to be considered in the Democratic-controlled Senate. And an attempt by Sen. Ron Wyden (D.-Ore.) to move the permanent SGR repeal forward and pay for it using the savings from the end of the wars in Iraq and Afghanistan failed to gain enough votes in the Senate.

Before the March 31 vote, Sen. Wyden chided fellow lawmakers for continuing to pass temporary fixes to the SGR problem rather than replacing it and moving to a payment system that incentivizes quality improvement. "It can’t be ducked much longer," he said.

But Sen. Orrin Hatch (R.-Utah), who worked on the bipartisan bill to replace the SGR, said he objects to the funding mechanism that Sen. Wyden proposed. He said the 12-month SGR patch will give lawmakers more time to agree on how to pay for a permanent fix. "I’m not going to make the perfect the enemy of the good," he said on the Senate floor.

[email protected]

On Twitter @maryellenny

In a last-minute move, Congress averted a scheduled 24% cut to Medicare physician fees slated to start on April 1, while simultaneously delaying the move to the ICD-10 coding sets.

On March 31, the Senate voted 64 to 35 to approve H.R. 4302, a bill that replaces the scheduled cut called for by the Medicare Sustainable Growth Rate formula with a 0.5% fee increase through the end of 2014 and a pay freeze from Jan. 1, 2015 through March 15, 2015. The bill also bars the Health and Human Services (HHS) department from implementing ICD-10 until Oct. 1, 2015.

Alicia Ault/Frontline Medical News

The House passed the same legislation on March 27. It now heads to the White House for President Obama’s signature.

At first glance, the bill looks like good news for physicians, who will get relief from both a hefty Medicare fee cut and a costly new regulatory requirement. But many physician organizations, led by the American Medical Association, have campaigned against the temporary patch, saying that it essentially stops the work to permanently repeal the SGR.

"It appears that an unprecedented, bipartisan agreement on Medicare reform is on the verge of being cast aside because elected leaders are unwilling to make tough choices to strengthen programs serving 50 million Americans," the AMA and more than 50 other medical societies wrote to congressional leaders before the House vote.

Several physician groups had endorsed a bipartisan legislative package that would have eliminated the SGR and replaced it with a combination of small fee increases and delivery system reforms. The hurdle to passing the legislation was finding a way to pay for it that would appeal to both Democrats and Republicans.

Recently, the House passed H.R. 4015, which would have funded the permanent SGR repeal package with a 5-year delay of the Affordable Care Act’s individual insurance mandate. But that bill is unlikely to be considered in the Democratic-controlled Senate. And an attempt by Sen. Ron Wyden (D.-Ore.) to move the permanent SGR repeal forward and pay for it using the savings from the end of the wars in Iraq and Afghanistan failed to gain enough votes in the Senate.

Before the March 31 vote, Sen. Wyden chided fellow lawmakers for continuing to pass temporary fixes to the SGR problem rather than replacing it and moving to a payment system that incentivizes quality improvement. "It can’t be ducked much longer," he said.

But Sen. Orrin Hatch (R.-Utah), who worked on the bipartisan bill to replace the SGR, said he objects to the funding mechanism that Sen. Wyden proposed. He said the 12-month SGR patch will give lawmakers more time to agree on how to pay for a permanent fix. "I’m not going to make the perfect the enemy of the good," he said on the Senate floor.

[email protected]

On Twitter @maryellenny

LAS VEGAS – Tired of getting a patient medication list that isn’t reliable? A 3-year study on medication reconciliation could offer a roadmap for improving that list and reducing potentially harmful errors.

Preliminary results from MARQUIS (the Multi-Center Medication Reconciliation Quality Improvement Study) indicate that hospitals are able to reduce unintentional medication discrepancies by implementing a menu of interventions ranging from training providers to take a better medication history to stationing a designated provider in the emergency department to reconcile the patient’s information with pharmacies and primary care offices. But outside forces, such as problems with an electronic health record (EHR) system, can offset those effects.

The 3-year study, which will wrap up in the next few months, is sponsored by the Society of Hospital Medicine, with $1.5 million in funding from the Agency for Healthcare Research and Quality.

In the first phase of the study, researchers identified evidence-based techniques for taking the best possible medication history from hospitalized patients and synthesized them into a toolkit for clinicians. The free toolkit includes how-to videos and pocket cards. The second phase of the study is the mentored implementation of the techniques at five sites: two academic medical centers, two community hospitals, and one Veterans Affairs medical center.

Initial results from two of the five sites show that training on how to take a better medication history and clarity about who should be working on reconciling the medication list can help improve medication discrepancies. But while the interventions are promising, the initial case studies show mixed results.

While one community hospital site was able to lower medication discrepancies significantly, a second community hospital site had a spike in its medication discrepancies as it underwent a problematic implementation of a new EHR system.

Eighteen minutes to win it

At the first site, a Medication Reconciliation Assistant (MRA) program was used to improve the reliability of medication lists. The MRA is stationed in the emergency department and interviews patients about their medications and then verifies that list with the pharmacy, the primary care physician, or the skilled nursing facility. That new medication list is then handed off to the admitting physician. The process usually takes about 18-20 minutes.

They MRA program is staffed by four full-time employees, all pharmacy technicians with experience in retail pharmacies, who work 8-hour shifts throughout the week.

"It doesn’t have to be a pharmacy technician," said Dr. Jason Stein, a MARQUIS coinvestigator and a professor of medicine at Emory University, Atlanta, at the annual meeting of the Society of Hospital Medicine. "But somebody needs to be spending that 18 minutes doing something that roughly looks like this."

At that first site, unintentional medication discrepancies from either history or reconciliation errors dropped from 4.5 per patient at the in the preintervention period to 3.4 per patient. And the total number of potentially harmful discrepancies was reduced from 0.25 to 0.09 per patient.

At the second site, a smaller community hospital, the quality improvement team provided training to front-line providers on medication history taking and counseling at discharge and created a new hospital policy that clarified expectations about who would perform medication reconciliation and when they would do it. And recently, they began stationing a provider in the emergency department 5 days a week to work on medication reconciliation.

But shortly after the second hospital began implementing the MARQUIS interventions, the hospital launched a new EHR system that created problems for medication reconciliation. For instance, with the paper system, the admitting physician was accountable for the initial medication history. But under the electronic system, that accountability was lost. Also, the new EHR was unable to group medications as "continued," "changed," "stopped," or "new," making it difficult to perform discharge medication counseling.

The result was that, after some initial success, unintentional medication discrepancies spiked. In the preintervention period, unintentional medication discrepancies were 2.0 per patient, but they rose to nearly 5 discrepancies per patient after the rollout of the new EHR system. They have since fallen back down to 3.8 per patient. Similarly, the total of potentially harmful discrepancies rose from 0.20 to 1.11 per patient.

The free MARQUIS toolkit is available online.

[email protected]

On Twitter @maryellenny

LAS VEGAS – Tired of getting a patient medication list that isn’t reliable? A 3-year study on medication reconciliation could offer a roadmap for improving that list and reducing potentially harmful errors.

Preliminary results from MARQUIS (the Multi-Center Medication Reconciliation Quality Improvement Study) indicate that hospitals are able to reduce unintentional medication discrepancies by implementing a menu of interventions ranging from training providers to take a better medication history to stationing a designated provider in the emergency department to reconcile the patient’s information with pharmacies and primary care offices. But outside forces, such as problems with an electronic health record (EHR) system, can offset those effects.

The 3-year study, which will wrap up in the next few months, is sponsored by the Society of Hospital Medicine, with $1.5 million in funding from the Agency for Healthcare Research and Quality.

In the first phase of the study, researchers identified evidence-based techniques for taking the best possible medication history from hospitalized patients and synthesized them into a toolkit for clinicians. The free toolkit includes how-to videos and pocket cards. The second phase of the study is the mentored implementation of the techniques at five sites: two academic medical centers, two community hospitals, and one Veterans Affairs medical center.

Initial results from two of the five sites show that training on how to take a better medication history and clarity about who should be working on reconciling the medication list can help improve medication discrepancies. But while the interventions are promising, the initial case studies show mixed results.

While one community hospital site was able to lower medication discrepancies significantly, a second community hospital site had a spike in its medication discrepancies as it underwent a problematic implementation of a new EHR system.

Eighteen minutes to win it

At the first site, a Medication Reconciliation Assistant (MRA) program was used to improve the reliability of medication lists. The MRA is stationed in the emergency department and interviews patients about their medications and then verifies that list with the pharmacy, the primary care physician, or the skilled nursing facility. That new medication list is then handed off to the admitting physician. The process usually takes about 18-20 minutes.

They MRA program is staffed by four full-time employees, all pharmacy technicians with experience in retail pharmacies, who work 8-hour shifts throughout the week.

"It doesn’t have to be a pharmacy technician," said Dr. Jason Stein, a MARQUIS coinvestigator and a professor of medicine at Emory University, Atlanta, at the annual meeting of the Society of Hospital Medicine. "But somebody needs to be spending that 18 minutes doing something that roughly looks like this."

At that first site, unintentional medication discrepancies from either history or reconciliation errors dropped from 4.5 per patient at the in the preintervention period to 3.4 per patient. And the total number of potentially harmful discrepancies was reduced from 0.25 to 0.09 per patient.

At the second site, a smaller community hospital, the quality improvement team provided training to front-line providers on medication history taking and counseling at discharge and created a new hospital policy that clarified expectations about who would perform medication reconciliation and when they would do it. And recently, they began stationing a provider in the emergency department 5 days a week to work on medication reconciliation.

But shortly after the second hospital began implementing the MARQUIS interventions, the hospital launched a new EHR system that created problems for medication reconciliation. For instance, with the paper system, the admitting physician was accountable for the initial medication history. But under the electronic system, that accountability was lost. Also, the new EHR was unable to group medications as "continued," "changed," "stopped," or "new," making it difficult to perform discharge medication counseling.

The result was that, after some initial success, unintentional medication discrepancies spiked. In the preintervention period, unintentional medication discrepancies were 2.0 per patient, but they rose to nearly 5 discrepancies per patient after the rollout of the new EHR system. They have since fallen back down to 3.8 per patient. Similarly, the total of potentially harmful discrepancies rose from 0.20 to 1.11 per patient.

The free MARQUIS toolkit is available online.

[email protected]

On Twitter @maryellenny

LAS VEGAS – Tired of getting a patient medication list that isn’t reliable? A 3-year study on medication reconciliation could offer a roadmap for improving that list and reducing potentially harmful errors.

Preliminary results from MARQUIS (the Multi-Center Medication Reconciliation Quality Improvement Study) indicate that hospitals are able to reduce unintentional medication discrepancies by implementing a menu of interventions ranging from training providers to take a better medication history to stationing a designated provider in the emergency department to reconcile the patient’s information with pharmacies and primary care offices. But outside forces, such as problems with an electronic health record (EHR) system, can offset those effects.

The 3-year study, which will wrap up in the next few months, is sponsored by the Society of Hospital Medicine, with $1.5 million in funding from the Agency for Healthcare Research and Quality.

In the first phase of the study, researchers identified evidence-based techniques for taking the best possible medication history from hospitalized patients and synthesized them into a toolkit for clinicians. The free toolkit includes how-to videos and pocket cards. The second phase of the study is the mentored implementation of the techniques at five sites: two academic medical centers, two community hospitals, and one Veterans Affairs medical center.

Initial results from two of the five sites show that training on how to take a better medication history and clarity about who should be working on reconciling the medication list can help improve medication discrepancies. But while the interventions are promising, the initial case studies show mixed results.

While one community hospital site was able to lower medication discrepancies significantly, a second community hospital site had a spike in its medication discrepancies as it underwent a problematic implementation of a new EHR system.

Eighteen minutes to win it

At the first site, a Medication Reconciliation Assistant (MRA) program was used to improve the reliability of medication lists. The MRA is stationed in the emergency department and interviews patients about their medications and then verifies that list with the pharmacy, the primary care physician, or the skilled nursing facility. That new medication list is then handed off to the admitting physician. The process usually takes about 18-20 minutes.

They MRA program is staffed by four full-time employees, all pharmacy technicians with experience in retail pharmacies, who work 8-hour shifts throughout the week.

"It doesn’t have to be a pharmacy technician," said Dr. Jason Stein, a MARQUIS coinvestigator and a professor of medicine at Emory University, Atlanta, at the annual meeting of the Society of Hospital Medicine. "But somebody needs to be spending that 18 minutes doing something that roughly looks like this."

At that first site, unintentional medication discrepancies from either history or reconciliation errors dropped from 4.5 per patient at the in the preintervention period to 3.4 per patient. And the total number of potentially harmful discrepancies was reduced from 0.25 to 0.09 per patient.

At the second site, a smaller community hospital, the quality improvement team provided training to front-line providers on medication history taking and counseling at discharge and created a new hospital policy that clarified expectations about who would perform medication reconciliation and when they would do it. And recently, they began stationing a provider in the emergency department 5 days a week to work on medication reconciliation.

But shortly after the second hospital began implementing the MARQUIS interventions, the hospital launched a new EHR system that created problems for medication reconciliation. For instance, with the paper system, the admitting physician was accountable for the initial medication history. But under the electronic system, that accountability was lost. Also, the new EHR was unable to group medications as "continued," "changed," "stopped," or "new," making it difficult to perform discharge medication counseling.

The result was that, after some initial success, unintentional medication discrepancies spiked. In the preintervention period, unintentional medication discrepancies were 2.0 per patient, but they rose to nearly 5 discrepancies per patient after the rollout of the new EHR system. They have since fallen back down to 3.8 per patient. Similarly, the total of potentially harmful discrepancies rose from 0.20 to 1.11 per patient.

The free MARQUIS toolkit is available online.

[email protected]

On Twitter @maryellenny

Legislation to delay the 24% Medicare pay cut based on the Sustainable Growth Rate formula passed the House by a voice vote March 27, despite the objections of a large coalition of physician organizations.

The Protecting Access to Medicare Act (H.R. 4302) would delay the SGR-mandated cut slated to take effect March 31, replace it with a 0.5% pay increase through the end of 2014, and freeze Medicare pay at that rate for the first quarter of 2015. The bill also would delay implementation of ICD-10 for 1 year.

Alicia Ault/Frontline Medical News

At press time, it was uncertain if the Senate would take up the bill.

Physicians organizations favor full repeal of the SGR and would like to see it replaced with a payment and delivery system reform policy that passed the House earlier this month as H.R. 4015. Financing for that legislation depended on a 5-year delay on the Affordable Care Act’s individual mandate, something most Democratic lawmakers do not support. H.R. 4015 had not been taken up by the Senate as the March 31 deadline loomed.

Prior to the vote, a coalition of 58 organizations called on the House to vote against the legislation.

"Instead of reforming the Medicare physician payment system, Congress seems intent on imposing yet another round of arbitrary provider payment reductions to maintain a corrosive policy that essentially every member of Congress says should be scrapped," the coalition wrote in a letter to House Speaker John Boehner (R-Ohio) and Minority Leader Nancy Pelosi (D-Calif.). "The endless cycle of short-term remedies that serve to support a failed policy are no longer acceptable."

[email protected]

On Twitter @denisefulton

Legislation to delay the 24% Medicare pay cut based on the Sustainable Growth Rate formula passed the House by a voice vote March 27, despite the objections of a large coalition of physician organizations.

The Protecting Access to Medicare Act (H.R. 4302) would delay the SGR-mandated cut slated to take effect March 31, replace it with a 0.5% pay increase through the end of 2014, and freeze Medicare pay at that rate for the first quarter of 2015. The bill also would delay implementation of ICD-10 for 1 year.

Alicia Ault/Frontline Medical News

At press time, it was uncertain if the Senate would take up the bill.

Physicians organizations favor full repeal of the SGR and would like to see it replaced with a payment and delivery system reform policy that passed the House earlier this month as H.R. 4015. Financing for that legislation depended on a 5-year delay on the Affordable Care Act’s individual mandate, something most Democratic lawmakers do not support. H.R. 4015 had not been taken up by the Senate as the March 31 deadline loomed.

Prior to the vote, a coalition of 58 organizations called on the House to vote against the legislation.

"Instead of reforming the Medicare physician payment system, Congress seems intent on imposing yet another round of arbitrary provider payment reductions to maintain a corrosive policy that essentially every member of Congress says should be scrapped," the coalition wrote in a letter to House Speaker John Boehner (R-Ohio) and Minority Leader Nancy Pelosi (D-Calif.). "The endless cycle of short-term remedies that serve to support a failed policy are no longer acceptable."

[email protected]

On Twitter @denisefulton

Legislation to delay the 24% Medicare pay cut based on the Sustainable Growth Rate formula passed the House by a voice vote March 27, despite the objections of a large coalition of physician organizations.

The Protecting Access to Medicare Act (H.R. 4302) would delay the SGR-mandated cut slated to take effect March 31, replace it with a 0.5% pay increase through the end of 2014, and freeze Medicare pay at that rate for the first quarter of 2015. The bill also would delay implementation of ICD-10 for 1 year.

Alicia Ault/Frontline Medical News

At press time, it was uncertain if the Senate would take up the bill.

Physicians organizations favor full repeal of the SGR and would like to see it replaced with a payment and delivery system reform policy that passed the House earlier this month as H.R. 4015. Financing for that legislation depended on a 5-year delay on the Affordable Care Act’s individual mandate, something most Democratic lawmakers do not support. H.R. 4015 had not been taken up by the Senate as the March 31 deadline loomed.

Prior to the vote, a coalition of 58 organizations called on the House to vote against the legislation.

"Instead of reforming the Medicare physician payment system, Congress seems intent on imposing yet another round of arbitrary provider payment reductions to maintain a corrosive policy that essentially every member of Congress says should be scrapped," the coalition wrote in a letter to House Speaker John Boehner (R-Ohio) and Minority Leader Nancy Pelosi (D-Calif.). "The endless cycle of short-term remedies that serve to support a failed policy are no longer acceptable."

[email protected]

On Twitter @denisefulton

Cash shortfalls related to the Oct. 1 switchover to ICD-10 "could be potentially devastating for a lot of practices," according to Dr. Barbara McAneny. That’s why she is setting up a $4 million line of credit to pay the bills and protect her practice in case claims are rejected and income is held up.

Health IT expert Stanley Nachimson agreed with her: Now is the time to prepare financially for the coming of ICD-10.

A plan has to be developed well before Oct. 1, said Mr. Nachimson, who has studied the cost of ICD-10 implementation for the American Medical Association.

"You have got to prepare for ICD-10 or you risk significant payment disruptions," he said at the AMA National Advocacy Conference in Washington.

Dr. McAneny, managing partner and chief executive officer of the New Mexico Cancer Center in Albuquerque, said that she’s already started talking to her local banker. She said she has very little faith that the ICD-10 transition will be smooth, given her experience in moving from the Health Insurance Portability and Accountability Act 4010 standard to the 5010 standard in 2011.

thinkstockphotos.com

"That was a much smaller event," said Dr. McAneny, who is also a member of the AMA Board of Trustees . And, with the change in HIPAA standards, the Centers for Medicare & Medicaid Services allowed for several transitional periods, where the old format continued to be accepted.

Dr. McAneny recalled that in 2011, the test runs were fine, and that both the clearinghouse and payer said that her practice was ready. But when the transition started, "we got denials like mad," she said in an interview. Some payers made no payments for 2-3 months.

This time, a substantial line of credit should be enough to cover 4 months of payroll, she said, adding that she anticipates hiring more coders and paying her billing staff extra to potentially chase denials.

"This transition has the potential to be a major disrupter," Dr. McAneny said.

Robert M. Tennant, senior policy adviser at the Medical Group Management Association (MGMA), said that physicians need to figure out soon how they will cover cash shortfalls, in part, because they may have to jump through a lot of hoops to satisfy a bank’s demands. "The days of supereasy credit are probably gone," he said in an interview.

He suggested arranging a line of credit to cover at least 2 months of operating expenses. A bank’s willingness to extend credit will depend on several variables, including the age of the practice, how long it’s been in its location, whether the practice owns or rents space, and what type of collateral is available to secure the line. In some cases, physicians might need to put up personal collateral.

"The hope, of course, is that you won’t have to tap into that line of credit very much, if at all," he said.

And it’s important to find out sooner rather than later how much credit can be secured. If it’s not enough to cover a few months’ expenses, practices might want to increase their cash reserves, Mr. Tennant said.

It’s important to "clear the decks" of any claims for services prior to Oct. 1, he said. Health plans will likely be overwhelmed by the transition, and that could lead to delays in payment for ICD-9 claims.

Mr. Nachimson said that practices should reach out to their major payers to get as much information as possible on changes in coverage policies and reimbursement for unspecified codes. "What they’re doing has a major impact on you," said Mr Nachimson.

Although many are still hoping for a delay in ICD-10, Mr. Tennant urged physicians to plan for the Oct. 1 implementation, "It’s too big a gamble for the practice to assume the date is going to be moved," he said. "If you bet the house and you lose, you’re going to be in a world of financial hurt."

The MGMA is suggesting that physicians "assume the worst and hope for the best," especially since there’s no real downside to improving documentation of diagnoses and getting staff better training in coding, he said.

[email protected]

On Twitter @aliciaault

Cash shortfalls related to the Oct. 1 switchover to ICD-10 "could be potentially devastating for a lot of practices," according to Dr. Barbara McAneny. That’s why she is setting up a $4 million line of credit to pay the bills and protect her practice in case claims are rejected and income is held up.

Health IT expert Stanley Nachimson agreed with her: Now is the time to prepare financially for the coming of ICD-10.

A plan has to be developed well before Oct. 1, said Mr. Nachimson, who has studied the cost of ICD-10 implementation for the American Medical Association.

"You have got to prepare for ICD-10 or you risk significant payment disruptions," he said at the AMA National Advocacy Conference in Washington.

Dr. McAneny, managing partner and chief executive officer of the New Mexico Cancer Center in Albuquerque, said that she’s already started talking to her local banker. She said she has very little faith that the ICD-10 transition will be smooth, given her experience in moving from the Health Insurance Portability and Accountability Act 4010 standard to the 5010 standard in 2011.

thinkstockphotos.com

"That was a much smaller event," said Dr. McAneny, who is also a member of the AMA Board of Trustees . And, with the change in HIPAA standards, the Centers for Medicare & Medicaid Services allowed for several transitional periods, where the old format continued to be accepted.

Dr. McAneny recalled that in 2011, the test runs were fine, and that both the clearinghouse and payer said that her practice was ready. But when the transition started, "we got denials like mad," she said in an interview. Some payers made no payments for 2-3 months.

This time, a substantial line of credit should be enough to cover 4 months of payroll, she said, adding that she anticipates hiring more coders and paying her billing staff extra to potentially chase denials.

"This transition has the potential to be a major disrupter," Dr. McAneny said.

Robert M. Tennant, senior policy adviser at the Medical Group Management Association (MGMA), said that physicians need to figure out soon how they will cover cash shortfalls, in part, because they may have to jump through a lot of hoops to satisfy a bank’s demands. "The days of supereasy credit are probably gone," he said in an interview.

He suggested arranging a line of credit to cover at least 2 months of operating expenses. A bank’s willingness to extend credit will depend on several variables, including the age of the practice, how long it’s been in its location, whether the practice owns or rents space, and what type of collateral is available to secure the line. In some cases, physicians might need to put up personal collateral.

"The hope, of course, is that you won’t have to tap into that line of credit very much, if at all," he said.

And it’s important to find out sooner rather than later how much credit can be secured. If it’s not enough to cover a few months’ expenses, practices might want to increase their cash reserves, Mr. Tennant said.

It’s important to "clear the decks" of any claims for services prior to Oct. 1, he said. Health plans will likely be overwhelmed by the transition, and that could lead to delays in payment for ICD-9 claims.

Mr. Nachimson said that practices should reach out to their major payers to get as much information as possible on changes in coverage policies and reimbursement for unspecified codes. "What they’re doing has a major impact on you," said Mr Nachimson.

Although many are still hoping for a delay in ICD-10, Mr. Tennant urged physicians to plan for the Oct. 1 implementation, "It’s too big a gamble for the practice to assume the date is going to be moved," he said. "If you bet the house and you lose, you’re going to be in a world of financial hurt."

The MGMA is suggesting that physicians "assume the worst and hope for the best," especially since there’s no real downside to improving documentation of diagnoses and getting staff better training in coding, he said.

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Cash shortfalls related to the Oct. 1 switchover to ICD-10 "could be potentially devastating for a lot of practices," according to Dr. Barbara McAneny. That’s why she is setting up a $4 million line of credit to pay the bills and protect her practice in case claims are rejected and income is held up.

Health IT expert Stanley Nachimson agreed with her: Now is the time to prepare financially for the coming of ICD-10.

A plan has to be developed well before Oct. 1, said Mr. Nachimson, who has studied the cost of ICD-10 implementation for the American Medical Association.

"You have got to prepare for ICD-10 or you risk significant payment disruptions," he said at the AMA National Advocacy Conference in Washington.

Dr. McAneny, managing partner and chief executive officer of the New Mexico Cancer Center in Albuquerque, said that she’s already started talking to her local banker. She said she has very little faith that the ICD-10 transition will be smooth, given her experience in moving from the Health Insurance Portability and Accountability Act 4010 standard to the 5010 standard in 2011.

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"That was a much smaller event," said Dr. McAneny, who is also a member of the AMA Board of Trustees . And, with the change in HIPAA standards, the Centers for Medicare & Medicaid Services allowed for several transitional periods, where the old format continued to be accepted.

Dr. McAneny recalled that in 2011, the test runs were fine, and that both the clearinghouse and payer said that her practice was ready. But when the transition started, "we got denials like mad," she said in an interview. Some payers made no payments for 2-3 months.

This time, a substantial line of credit should be enough to cover 4 months of payroll, she said, adding that she anticipates hiring more coders and paying her billing staff extra to potentially chase denials.

"This transition has the potential to be a major disrupter," Dr. McAneny said.

Robert M. Tennant, senior policy adviser at the Medical Group Management Association (MGMA), said that physicians need to figure out soon how they will cover cash shortfalls, in part, because they may have to jump through a lot of hoops to satisfy a bank’s demands. "The days of supereasy credit are probably gone," he said in an interview.

He suggested arranging a line of credit to cover at least 2 months of operating expenses. A bank’s willingness to extend credit will depend on several variables, including the age of the practice, how long it’s been in its location, whether the practice owns or rents space, and what type of collateral is available to secure the line. In some cases, physicians might need to put up personal collateral.

"The hope, of course, is that you won’t have to tap into that line of credit very much, if at all," he said.

And it’s important to find out sooner rather than later how much credit can be secured. If it’s not enough to cover a few months’ expenses, practices might want to increase their cash reserves, Mr. Tennant said.

It’s important to "clear the decks" of any claims for services prior to Oct. 1, he said. Health plans will likely be overwhelmed by the transition, and that could lead to delays in payment for ICD-9 claims.

Mr. Nachimson said that practices should reach out to their major payers to get as much information as possible on changes in coverage policies and reimbursement for unspecified codes. "What they’re doing has a major impact on you," said Mr Nachimson.

Although many are still hoping for a delay in ICD-10, Mr. Tennant urged physicians to plan for the Oct. 1 implementation, "It’s too big a gamble for the practice to assume the date is going to be moved," he said. "If you bet the house and you lose, you’re going to be in a world of financial hurt."

The MGMA is suggesting that physicians "assume the worst and hope for the best," especially since there’s no real downside to improving documentation of diagnoses and getting staff better training in coding, he said.

[email protected]

On Twitter @aliciaault