Practice Management

The extent of the exam should correspond to the nature of the presenting problem, the standard of care, and the physicians’ clinical judgment. Remember, medical necessity issues can arise if the physician performs and submits a claim for a comprehensive service involving a self-limiting problem. The easiest way to demonstrate the medical necessity for evaluation and management (E/M) services is through medical decision-making. It prevents a third party from making accusations that a Level 5 service was reported solely based upon a comprehensive history and examination that was not warranted by the patient’s presenting problem (e.g. the common cold).¹

1995 Exam Guidelines

The 1995 guidelines differentiate 10 body areas (head and face; neck; chest, breast, and axillae; abdomen; genitalia, groin, and buttocks; back and spine; right upper extremity; left upper extremity; right lower extremity; and left lower extremity) from 12 organ systems (constitutional; eyes; ears, nose, mouth, and throat; cardiovascular; respiratory, gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; hematologic, lymphatic, and immunologic).² Physicians are permitted to perform and comment without mandate, as appropriate, but with a few minor directives:

• Document relevant negative findings. Commenting that a system or area is “negative” or “normal” is acceptable when referring to unaffected areas or asymptomatic organ systems.
• Elaborate abnormal findings. Commenting that a system or area is “abnormal” is not sufficient unless additional comments describing the abnormality are documented.

1997 Documentation Guidelines

The 1997 guidelines are formatted as organ systems with corresponding, bulleted items referred to as “elements.”³ Additionally, a few elements have a numeric requirement to be achieved before satisfying the documentation of that particular element. For example, credit for the “vital signs element” (located within the constitutional system) is only awarded after documentation of three individual measurements (e.g. blood pressure, heart rate, and respiratory rate). Failure to document the specified criterion (e.g. two measurements: “blood pressure and heart rate only,” or a single nonspecific comment: “vital signs stable”) leads to failure to assign credit.

Take note that these specified criterion do not resonate within the 1995 guidelines. Numerical requirements also are indicated for the lymphatic system. The physician must examine and document findings associated with two or more lymphatic areas (e.g. “no lymphadenopathy noted in the neck or axillae”).

In the absence of numeric criterion, some elements contain multiple components, which require documentation of at least one component. For example, one listed psychiatric element designates the assessment of the patient’s “mood and affect.” The physician receives credit for a comment regarding the patient’s mood (e.g. “appears depressed”) without identification of a flat (or normal).

click for large version

The 1997 Documentation Guide-lines comprise the following systems and elements:

Constitutional

• Measurement of any three of the following seven vital signs:

  1. Sitting or standing blood pressure;
  2. Supine blood pressure;
  3. Pulse rate and regularity;
  4. Respiration;
  5. Temperature;
  6. Height; or
  7. Weight (can be measured and recorded by ancillary staff).

• General appearance of patient (e.g. development, nutrition, body habitus, deformities, attention to grooming)

Eyes

• Inspection of conjunctivae and lids;
• Examination of pupils and irises (e.g. reaction to light and accommodation, size, symmetry); and
• Ophthalmoscopic examination of optic discs (e.g. size, C/D ratio, appearance) and posterior segments (e.g. vessel changes, exudates, hemorrhages).

click for large version

click for large version

Ears, Nose, Mouth, and Throat

• External inspection of ears and nose (e.g. overall appearance, scars, lesions, masses);
• Otoscopic examination of external auditory canals and tympanic membranes;
• Assessment of hearing (e.g. whispered voice, finger rub, tuning fork);
• Inspection of nasal mucosa, septum, and turbinates;
• Inspection of lips, teeth, and gums; and
• Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx.

Neck

• Examination of neck (e.g. masses, overall appearance, symmetry, tracheal position, crepitus); and
• Examination of thyroid (e.g. enlargement, tenderness, mass).

Respiratory

• Assessment of respiratory effort (e.g. intercostal retractions, use of accessory muscles, diaphragmatic movement);
• Percussion of chest (e.g. dullness, flatness, hyperresonance);
• Palpation of chest (e.g. tactile fremitus); and
• Auscultation of lungs (e.g. breath sounds, adventitious sounds, rubs).

Cardiovascular

• Palpation of heart (e.g. location, size, thrills);
• Auscultation of heart with notation of abnormal sounds and murmurs; and
• Examination of:

  • Carotid arteries (e.g. pulse amplitude, bruits);
  • Abdominal aorta (e.g. size, bruits);
  • Femoral arteries (e.g. pulse amplitude, bruits);
  • Pedal pulses (e.g. pulse amplitude); and
  • Extremities for edema and/or varicosities.

Chest

• Inspection of breasts (e.g. symmetry, nipple discharge); and
• Palpation of breasts and axillae (e.g. masses or lumps, tenderness).

Gastrointestinal

• Examination of abdomen with notation of presence of masses or tenderness;
• Examination of liver and spleen;
• Examination for presence or absence of hernia;
• Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, and rectal masses; and
• Obtain stool sample for occult blood test when indicated.

Genitourinary (Male)

• Examination of the scrotal contents (e.g. hydrocele, spermatocele, tenderness of cord, testicular mass);
• Examination of the penis; and
• Digital rectal examination of prostate gland (e.g. size, symmetry, nodularity, tenderness).

Genitourinary (Female)

• Pelvic examination (with or without specimen collection for smears and cultures), including:

  • Examination of external genitalia (e.g. general appearance, hair distribution, lesions) and vagina (e.g. general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele);
  • Examination of urethra (e.g. masses, tenderness, scarring);
  • Examination of bladder (e.g. fullness, masses, tenderness);
  • Cervix (e.g. general appearance, lesions, discharge);
  • Uterus (e.g. size, contour, position, mobility, tenderness, consistency, descent or support); and
  • Adnexa/parametria (e.g. masses, tenderness, organomegaly, nodularity).

• Lymphatic Palpation of lymph nodes in two or more areas: Neck, axillae, groin, other.

Musculoskeletal

• Examination of gait and station;
• Inspection and/or palpation of digits and nails (e.g. clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes);
• Examination of joints, bones and muscles of one or more of the following six areas:

  1. head and neck;
  2. spine, ribs and pelvis;
  3. right upper extremity;
  4. left upper extremity;
  5. right lower extremity; and
  6. left lower extremity.

The examination of a given area includes:

• Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions;
• Assessment of range of motion with notation of any pain, crepitation or contracture;
• Assessment of stability with notation of any dislocation (luxation), subluxation or laxity; and
• Assessment of muscle strength and tone (e.g. flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.

Skin

• Inspection of skin and subcutaneous tissue (e.g. rashes, lesions, ulcers); and
• Palpation of skin and subcutaneous tissue (e.g. induration, subcutaneous nodules, tightening).

Neurologic

• Test cranial nerves with notation of any deficits;
• Examination of deep tendon reflexes with notation of pathological reflexes (e.g. Babinski); and
• Examination of sensation (e.g. by touch, pin, vibration, proprioception).

Psychiatric

• Description of patient’s judgment and insight;
• Brief assessment of mental status, including:

  • Orientation to time, place, and person;
  • Recent and remote memory; and
  • Mood and affect (e.g. depression, anxiety, agitation).

Considerations

The 1997 Documentation Guidelines often are criticized for their “specific” nature. Although this assists the auditor, it hinders the physician. The consequence is difficulty and frustration with remembering the explicit comments and number of elements associated with each level of exam. As a solution, consider documentation templates—paper or electronic—that incorporate cues and prompts for normal exam findings with adequate space for elaboration of abnormal findings.

Remember that both sets of guidelines apply to visit level selection, and physicians may utilize either set when documenting their services. Auditors will review documentation with each of the guidelines, and assign the final audited result as the highest visit level supported during the comparison. Physicians should use the set that is best for their patients, practice, and peace of mind.

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

References

1. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2010. Northbrook, Ill.: American College of Chest Physicians; 2009:87-118.
2. Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf. Accessed Sept. 12, 2011.
3. Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed Sept. 12, 2011.
4. Highmark Medicare Services. Frequently Asked Questions: Evaluation And Management Services (Part B). Available at: http://www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html#10. Accessed Sept. 14, 2011.
5. Centers for Medicare & Medicaid Services. Transmittal 2282: Clarification of Evaluation and Management Payment Policy. Available at: http://www.cms.gov/transmittals/downloads/R2282CP.pdf. Accessed Sept. 15, 2011.
6. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011:1-20.

The extent of the exam should correspond to the nature of the presenting problem, the standard of care, and the physicians’ clinical judgment. Remember, medical necessity issues can arise if the physician performs and submits a claim for a comprehensive service involving a self-limiting problem. The easiest way to demonstrate the medical necessity for evaluation and management (E/M) services is through medical decision-making. It prevents a third party from making accusations that a Level 5 service was reported solely based upon a comprehensive history and examination that was not warranted by the patient’s presenting problem (e.g. the common cold).¹

1995 Exam Guidelines

The 1995 guidelines differentiate 10 body areas (head and face; neck; chest, breast, and axillae; abdomen; genitalia, groin, and buttocks; back and spine; right upper extremity; left upper extremity; right lower extremity; and left lower extremity) from 12 organ systems (constitutional; eyes; ears, nose, mouth, and throat; cardiovascular; respiratory, gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; hematologic, lymphatic, and immunologic).² Physicians are permitted to perform and comment without mandate, as appropriate, but with a few minor directives:

• Document relevant negative findings. Commenting that a system or area is “negative” or “normal” is acceptable when referring to unaffected areas or asymptomatic organ systems.
• Elaborate abnormal findings. Commenting that a system or area is “abnormal” is not sufficient unless additional comments describing the abnormality are documented.

1997 Documentation Guidelines

The 1997 guidelines are formatted as organ systems with corresponding, bulleted items referred to as “elements.”³ Additionally, a few elements have a numeric requirement to be achieved before satisfying the documentation of that particular element. For example, credit for the “vital signs element” (located within the constitutional system) is only awarded after documentation of three individual measurements (e.g. blood pressure, heart rate, and respiratory rate). Failure to document the specified criterion (e.g. two measurements: “blood pressure and heart rate only,” or a single nonspecific comment: “vital signs stable”) leads to failure to assign credit.

Take note that these specified criterion do not resonate within the 1995 guidelines. Numerical requirements also are indicated for the lymphatic system. The physician must examine and document findings associated with two or more lymphatic areas (e.g. “no lymphadenopathy noted in the neck or axillae”).

In the absence of numeric criterion, some elements contain multiple components, which require documentation of at least one component. For example, one listed psychiatric element designates the assessment of the patient’s “mood and affect.” The physician receives credit for a comment regarding the patient’s mood (e.g. “appears depressed”) without identification of a flat (or normal).

click for large version

The 1997 Documentation Guide-lines comprise the following systems and elements:

Constitutional

• Measurement of any three of the following seven vital signs:

  1. Sitting or standing blood pressure;
  2. Supine blood pressure;
  3. Pulse rate and regularity;
  4. Respiration;
  5. Temperature;
  6. Height; or
  7. Weight (can be measured and recorded by ancillary staff).

• General appearance of patient (e.g. development, nutrition, body habitus, deformities, attention to grooming)

Eyes

• Inspection of conjunctivae and lids;
• Examination of pupils and irises (e.g. reaction to light and accommodation, size, symmetry); and
• Ophthalmoscopic examination of optic discs (e.g. size, C/D ratio, appearance) and posterior segments (e.g. vessel changes, exudates, hemorrhages).

click for large version

click for large version

Ears, Nose, Mouth, and Throat

• External inspection of ears and nose (e.g. overall appearance, scars, lesions, masses);
• Otoscopic examination of external auditory canals and tympanic membranes;
• Assessment of hearing (e.g. whispered voice, finger rub, tuning fork);
• Inspection of nasal mucosa, septum, and turbinates;
• Inspection of lips, teeth, and gums; and
• Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx.

Neck

• Examination of neck (e.g. masses, overall appearance, symmetry, tracheal position, crepitus); and
• Examination of thyroid (e.g. enlargement, tenderness, mass).

Respiratory

• Assessment of respiratory effort (e.g. intercostal retractions, use of accessory muscles, diaphragmatic movement);
• Percussion of chest (e.g. dullness, flatness, hyperresonance);
• Palpation of chest (e.g. tactile fremitus); and
• Auscultation of lungs (e.g. breath sounds, adventitious sounds, rubs).

Cardiovascular

• Palpation of heart (e.g. location, size, thrills);
• Auscultation of heart with notation of abnormal sounds and murmurs; and
• Examination of:

  • Carotid arteries (e.g. pulse amplitude, bruits);
  • Abdominal aorta (e.g. size, bruits);
  • Femoral arteries (e.g. pulse amplitude, bruits);
  • Pedal pulses (e.g. pulse amplitude); and
  • Extremities for edema and/or varicosities.

Chest

• Inspection of breasts (e.g. symmetry, nipple discharge); and
• Palpation of breasts and axillae (e.g. masses or lumps, tenderness).

Gastrointestinal

• Examination of abdomen with notation of presence of masses or tenderness;
• Examination of liver and spleen;
• Examination for presence or absence of hernia;
• Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, and rectal masses; and
• Obtain stool sample for occult blood test when indicated.

Genitourinary (Male)

• Examination of the scrotal contents (e.g. hydrocele, spermatocele, tenderness of cord, testicular mass);
• Examination of the penis; and
• Digital rectal examination of prostate gland (e.g. size, symmetry, nodularity, tenderness).

Genitourinary (Female)

• Pelvic examination (with or without specimen collection for smears and cultures), including:

  • Examination of external genitalia (e.g. general appearance, hair distribution, lesions) and vagina (e.g. general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele);
  • Examination of urethra (e.g. masses, tenderness, scarring);
  • Examination of bladder (e.g. fullness, masses, tenderness);
  • Cervix (e.g. general appearance, lesions, discharge);
  • Uterus (e.g. size, contour, position, mobility, tenderness, consistency, descent or support); and
  • Adnexa/parametria (e.g. masses, tenderness, organomegaly, nodularity).

• Lymphatic Palpation of lymph nodes in two or more areas: Neck, axillae, groin, other.

Musculoskeletal

• Examination of gait and station;
• Inspection and/or palpation of digits and nails (e.g. clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes);
• Examination of joints, bones and muscles of one or more of the following six areas:

  1. head and neck;
  2. spine, ribs and pelvis;
  3. right upper extremity;
  4. left upper extremity;
  5. right lower extremity; and
  6. left lower extremity.

The examination of a given area includes:

• Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions;
• Assessment of range of motion with notation of any pain, crepitation or contracture;
• Assessment of stability with notation of any dislocation (luxation), subluxation or laxity; and
• Assessment of muscle strength and tone (e.g. flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.

Skin

• Inspection of skin and subcutaneous tissue (e.g. rashes, lesions, ulcers); and
• Palpation of skin and subcutaneous tissue (e.g. induration, subcutaneous nodules, tightening).

Neurologic

• Test cranial nerves with notation of any deficits;
• Examination of deep tendon reflexes with notation of pathological reflexes (e.g. Babinski); and
• Examination of sensation (e.g. by touch, pin, vibration, proprioception).

Psychiatric

• Description of patient’s judgment and insight;
• Brief assessment of mental status, including:

  • Orientation to time, place, and person;
  • Recent and remote memory; and
  • Mood and affect (e.g. depression, anxiety, agitation).

Considerations

The 1997 Documentation Guidelines often are criticized for their “specific” nature. Although this assists the auditor, it hinders the physician. The consequence is difficulty and frustration with remembering the explicit comments and number of elements associated with each level of exam. As a solution, consider documentation templates—paper or electronic—that incorporate cues and prompts for normal exam findings with adequate space for elaboration of abnormal findings.

Remember that both sets of guidelines apply to visit level selection, and physicians may utilize either set when documenting their services. Auditors will review documentation with each of the guidelines, and assign the final audited result as the highest visit level supported during the comparison. Physicians should use the set that is best for their patients, practice, and peace of mind.

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

References

1. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2010. Northbrook, Ill.: American College of Chest Physicians; 2009:87-118.
2. Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf. Accessed Sept. 12, 2011.
3. Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed Sept. 12, 2011.
4. Highmark Medicare Services. Frequently Asked Questions: Evaluation And Management Services (Part B). Available at: http://www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html#10. Accessed Sept. 14, 2011.
5. Centers for Medicare & Medicaid Services. Transmittal 2282: Clarification of Evaluation and Management Payment Policy. Available at: http://www.cms.gov/transmittals/downloads/R2282CP.pdf. Accessed Sept. 15, 2011.
6. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011:1-20.

The extent of the exam should correspond to the nature of the presenting problem, the standard of care, and the physicians’ clinical judgment. Remember, medical necessity issues can arise if the physician performs and submits a claim for a comprehensive service involving a self-limiting problem. The easiest way to demonstrate the medical necessity for evaluation and management (E/M) services is through medical decision-making. It prevents a third party from making accusations that a Level 5 service was reported solely based upon a comprehensive history and examination that was not warranted by the patient’s presenting problem (e.g. the common cold).¹

1995 Exam Guidelines

The 1995 guidelines differentiate 10 body areas (head and face; neck; chest, breast, and axillae; abdomen; genitalia, groin, and buttocks; back and spine; right upper extremity; left upper extremity; right lower extremity; and left lower extremity) from 12 organ systems (constitutional; eyes; ears, nose, mouth, and throat; cardiovascular; respiratory, gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; hematologic, lymphatic, and immunologic).² Physicians are permitted to perform and comment without mandate, as appropriate, but with a few minor directives:

• Document relevant negative findings. Commenting that a system or area is “negative” or “normal” is acceptable when referring to unaffected areas or asymptomatic organ systems.
• Elaborate abnormal findings. Commenting that a system or area is “abnormal” is not sufficient unless additional comments describing the abnormality are documented.

1997 Documentation Guidelines

The 1997 guidelines are formatted as organ systems with corresponding, bulleted items referred to as “elements.”³ Additionally, a few elements have a numeric requirement to be achieved before satisfying the documentation of that particular element. For example, credit for the “vital signs element” (located within the constitutional system) is only awarded after documentation of three individual measurements (e.g. blood pressure, heart rate, and respiratory rate). Failure to document the specified criterion (e.g. two measurements: “blood pressure and heart rate only,” or a single nonspecific comment: “vital signs stable”) leads to failure to assign credit.

Take note that these specified criterion do not resonate within the 1995 guidelines. Numerical requirements also are indicated for the lymphatic system. The physician must examine and document findings associated with two or more lymphatic areas (e.g. “no lymphadenopathy noted in the neck or axillae”).

In the absence of numeric criterion, some elements contain multiple components, which require documentation of at least one component. For example, one listed psychiatric element designates the assessment of the patient’s “mood and affect.” The physician receives credit for a comment regarding the patient’s mood (e.g. “appears depressed”) without identification of a flat (or normal).

click for large version

The 1997 Documentation Guide-lines comprise the following systems and elements:

Constitutional

• Measurement of any three of the following seven vital signs:

  1. Sitting or standing blood pressure;
  2. Supine blood pressure;
  3. Pulse rate and regularity;
  4. Respiration;
  5. Temperature;
  6. Height; or
  7. Weight (can be measured and recorded by ancillary staff).

• General appearance of patient (e.g. development, nutrition, body habitus, deformities, attention to grooming)

Eyes

• Inspection of conjunctivae and lids;
• Examination of pupils and irises (e.g. reaction to light and accommodation, size, symmetry); and
• Ophthalmoscopic examination of optic discs (e.g. size, C/D ratio, appearance) and posterior segments (e.g. vessel changes, exudates, hemorrhages).

click for large version

click for large version

Ears, Nose, Mouth, and Throat

• External inspection of ears and nose (e.g. overall appearance, scars, lesions, masses);
• Otoscopic examination of external auditory canals and tympanic membranes;
• Assessment of hearing (e.g. whispered voice, finger rub, tuning fork);
• Inspection of nasal mucosa, septum, and turbinates;
• Inspection of lips, teeth, and gums; and
• Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx.

Neck

• Examination of neck (e.g. masses, overall appearance, symmetry, tracheal position, crepitus); and
• Examination of thyroid (e.g. enlargement, tenderness, mass).

Respiratory

• Assessment of respiratory effort (e.g. intercostal retractions, use of accessory muscles, diaphragmatic movement);
• Percussion of chest (e.g. dullness, flatness, hyperresonance);
• Palpation of chest (e.g. tactile fremitus); and
• Auscultation of lungs (e.g. breath sounds, adventitious sounds, rubs).

Cardiovascular

• Palpation of heart (e.g. location, size, thrills);
• Auscultation of heart with notation of abnormal sounds and murmurs; and
• Examination of:

  • Carotid arteries (e.g. pulse amplitude, bruits);
  • Abdominal aorta (e.g. size, bruits);
  • Femoral arteries (e.g. pulse amplitude, bruits);
  • Pedal pulses (e.g. pulse amplitude); and
  • Extremities for edema and/or varicosities.

Chest

• Inspection of breasts (e.g. symmetry, nipple discharge); and
• Palpation of breasts and axillae (e.g. masses or lumps, tenderness).

Gastrointestinal

• Examination of abdomen with notation of presence of masses or tenderness;
• Examination of liver and spleen;
• Examination for presence or absence of hernia;
• Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, and rectal masses; and
• Obtain stool sample for occult blood test when indicated.

Genitourinary (Male)

• Examination of the scrotal contents (e.g. hydrocele, spermatocele, tenderness of cord, testicular mass);
• Examination of the penis; and
• Digital rectal examination of prostate gland (e.g. size, symmetry, nodularity, tenderness).

Genitourinary (Female)

• Pelvic examination (with or without specimen collection for smears and cultures), including:

  • Examination of external genitalia (e.g. general appearance, hair distribution, lesions) and vagina (e.g. general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele);
  • Examination of urethra (e.g. masses, tenderness, scarring);
  • Examination of bladder (e.g. fullness, masses, tenderness);
  • Cervix (e.g. general appearance, lesions, discharge);
  • Uterus (e.g. size, contour, position, mobility, tenderness, consistency, descent or support); and
  • Adnexa/parametria (e.g. masses, tenderness, organomegaly, nodularity).

• Lymphatic Palpation of lymph nodes in two or more areas: Neck, axillae, groin, other.

Musculoskeletal

• Examination of gait and station;
• Inspection and/or palpation of digits and nails (e.g. clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes);
• Examination of joints, bones and muscles of one or more of the following six areas:

  1. head and neck;
  2. spine, ribs and pelvis;
  3. right upper extremity;
  4. left upper extremity;
  5. right lower extremity; and
  6. left lower extremity.

The examination of a given area includes:

• Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions;
• Assessment of range of motion with notation of any pain, crepitation or contracture;
• Assessment of stability with notation of any dislocation (luxation), subluxation or laxity; and
• Assessment of muscle strength and tone (e.g. flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.

Skin

• Inspection of skin and subcutaneous tissue (e.g. rashes, lesions, ulcers); and
• Palpation of skin and subcutaneous tissue (e.g. induration, subcutaneous nodules, tightening).

Neurologic

• Test cranial nerves with notation of any deficits;
• Examination of deep tendon reflexes with notation of pathological reflexes (e.g. Babinski); and
• Examination of sensation (e.g. by touch, pin, vibration, proprioception).

Psychiatric

• Description of patient’s judgment and insight;
• Brief assessment of mental status, including:

  • Orientation to time, place, and person;
  • Recent and remote memory; and
  • Mood and affect (e.g. depression, anxiety, agitation).

Considerations

The 1997 Documentation Guidelines often are criticized for their “specific” nature. Although this assists the auditor, it hinders the physician. The consequence is difficulty and frustration with remembering the explicit comments and number of elements associated with each level of exam. As a solution, consider documentation templates—paper or electronic—that incorporate cues and prompts for normal exam findings with adequate space for elaboration of abnormal findings.

Remember that both sets of guidelines apply to visit level selection, and physicians may utilize either set when documenting their services. Auditors will review documentation with each of the guidelines, and assign the final audited result as the highest visit level supported during the comparison. Physicians should use the set that is best for their patients, practice, and peace of mind.

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

References

1. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2010. Northbrook, Ill.: American College of Chest Physicians; 2009:87-118.
2. Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf. Accessed Sept. 12, 2011.
3. Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed Sept. 12, 2011.
4. Highmark Medicare Services. Frequently Asked Questions: Evaluation And Management Services (Part B). Available at: http://www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html#10. Accessed Sept. 14, 2011.
5. Centers for Medicare & Medicaid Services. Transmittal 2282: Clarification of Evaluation and Management Payment Policy. Available at: http://www.cms.gov/transmittals/downloads/R2282CP.pdf. Accessed Sept. 15, 2011.
6. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011:1-20.

I recently became chief medical officer (CMO) of our hospital. When a hospitalist’s case comes to our patient-care committee, is it appropriate to inform the patient’s primary-care physician (PCP) of the quality issues? Our hospitalists are independent. There are questions of HIPAA. However, several committee members feel that the PCP, who does not come to the hospital, should be informed. Thank you.

K.A., M.D.

Dr. Hospitalist responds:

Good question. While I’ve participated in similar scenarios, keep in mind that I’m a hospitalist like you, not a lawyer. So, with that rejoinder in mind, let’s take this discussion a few steps further and see what happens.

You state: “when a hospitalist’s case comes to our patient-care committee.” Does that mean peer review? If it does, and what you are describing is a committee that handles privileged and confidential information, then you cannot inform the PCP because you would be violating the basic tenets of peer review.

The principle behind peer review is that it allows physicians to confidentially review the cases of their peers. This is to prevent the information contained in peer review from becoming available to a lawyer by subpoena or by discovery in the courts. The Joint Commission has mandated hospital peer review committees since 1952, and the federal government included language regarding peer-review protection in the Health Care Quality Improvement Act of 1986.

Every state has a law on the books, but the specifics and effectiveness of peer review will vary from state to state (see Florida’s Amendment 7, Kentucky, and Massachusetts). The whole idea is to allow for a process to evaluate physician practice or quality concerns without the fear of discovery or subsequent lawsuit. Even the act of referring a case to peer review is considered a confidential action in my state, so just the referral itself may not be discussed. So if you are referring to peer review, the answer is no, you cannot inform the patient’s PCP. HIPAA does not come into the picture here.

On the other hand, let’s assume, for sake of discussion, that you’ve heard a complaint (or several) about a certain hospitalist, Dr. Nogood. You could, if you desired, refer these complaints to peer review.

If so, then you are immediately bound by those rules of confidentiality. If you don’t refer the case, then you could inform the PCP that you have heard a complaint involving Dr. Nogood and that PCP’s patient.

I can’t see how that would violate HIPAA, because the PCP has an established relationship with that patient, and you might be only reporting facts (the complaint), not passing judgment on the quality of care. And I would not even go that far.

Why stop there? Why not tell that PCP exactly what you think of Dr. Nogood and his clinical practice, the details of the complaints against him, and how you think maybe that PCP should send his patients to someone else for better care? Well, you’re the CMO for the hospital. If you go beyond reporting facts and start reporting opinions, then you’ve just opened yourself up to accusations of restraint of trade by Dr. Nogood.

No matter what you may think of Dr. Nogood’s patient care, unless it falls outside the boundaries of acceptable practice (which can only be determined by a peer review committee), then you should not say anything.

Unless, of course, you want to be accused of spreading rumors, hearsay, and innuendo. Remember, we are talking about an independent practitioner, not a hospital employee.

Overall, it’s a bit of a sticky wicket. If you think the complaint has merit, then it should be sent to peer review—and you may speak no more of it. If you think the complaint is baseless, then why sustain it and tell the PCP?

Peer review is an exceptional process, and the physicians who serve on such committees perform a difficult and selfless service. We should all do our best to uphold its integrity.

I recently became chief medical officer (CMO) of our hospital. When a hospitalist’s case comes to our patient-care committee, is it appropriate to inform the patient’s primary-care physician (PCP) of the quality issues? Our hospitalists are independent. There are questions of HIPAA. However, several committee members feel that the PCP, who does not come to the hospital, should be informed. Thank you.

K.A., M.D.

Dr. Hospitalist responds:

Good question. While I’ve participated in similar scenarios, keep in mind that I’m a hospitalist like you, not a lawyer. So, with that rejoinder in mind, let’s take this discussion a few steps further and see what happens.

You state: “when a hospitalist’s case comes to our patient-care committee.” Does that mean peer review? If it does, and what you are describing is a committee that handles privileged and confidential information, then you cannot inform the PCP because you would be violating the basic tenets of peer review.

The principle behind peer review is that it allows physicians to confidentially review the cases of their peers. This is to prevent the information contained in peer review from becoming available to a lawyer by subpoena or by discovery in the courts. The Joint Commission has mandated hospital peer review committees since 1952, and the federal government included language regarding peer-review protection in the Health Care Quality Improvement Act of 1986.

Every state has a law on the books, but the specifics and effectiveness of peer review will vary from state to state (see Florida’s Amendment 7, Kentucky, and Massachusetts). The whole idea is to allow for a process to evaluate physician practice or quality concerns without the fear of discovery or subsequent lawsuit. Even the act of referring a case to peer review is considered a confidential action in my state, so just the referral itself may not be discussed. So if you are referring to peer review, the answer is no, you cannot inform the patient’s PCP. HIPAA does not come into the picture here.

On the other hand, let’s assume, for sake of discussion, that you’ve heard a complaint (or several) about a certain hospitalist, Dr. Nogood. You could, if you desired, refer these complaints to peer review.

If so, then you are immediately bound by those rules of confidentiality. If you don’t refer the case, then you could inform the PCP that you have heard a complaint involving Dr. Nogood and that PCP’s patient.

I can’t see how that would violate HIPAA, because the PCP has an established relationship with that patient, and you might be only reporting facts (the complaint), not passing judgment on the quality of care. And I would not even go that far.

Why stop there? Why not tell that PCP exactly what you think of Dr. Nogood and his clinical practice, the details of the complaints against him, and how you think maybe that PCP should send his patients to someone else for better care? Well, you’re the CMO for the hospital. If you go beyond reporting facts and start reporting opinions, then you’ve just opened yourself up to accusations of restraint of trade by Dr. Nogood.

No matter what you may think of Dr. Nogood’s patient care, unless it falls outside the boundaries of acceptable practice (which can only be determined by a peer review committee), then you should not say anything.

Unless, of course, you want to be accused of spreading rumors, hearsay, and innuendo. Remember, we are talking about an independent practitioner, not a hospital employee.

Overall, it’s a bit of a sticky wicket. If you think the complaint has merit, then it should be sent to peer review—and you may speak no more of it. If you think the complaint is baseless, then why sustain it and tell the PCP?

Peer review is an exceptional process, and the physicians who serve on such committees perform a difficult and selfless service. We should all do our best to uphold its integrity.

I recently became chief medical officer (CMO) of our hospital. When a hospitalist’s case comes to our patient-care committee, is it appropriate to inform the patient’s primary-care physician (PCP) of the quality issues? Our hospitalists are independent. There are questions of HIPAA. However, several committee members feel that the PCP, who does not come to the hospital, should be informed. Thank you.

K.A., M.D.

Dr. Hospitalist responds:

Good question. While I’ve participated in similar scenarios, keep in mind that I’m a hospitalist like you, not a lawyer. So, with that rejoinder in mind, let’s take this discussion a few steps further and see what happens.

You state: “when a hospitalist’s case comes to our patient-care committee.” Does that mean peer review? If it does, and what you are describing is a committee that handles privileged and confidential information, then you cannot inform the PCP because you would be violating the basic tenets of peer review.

The principle behind peer review is that it allows physicians to confidentially review the cases of their peers. This is to prevent the information contained in peer review from becoming available to a lawyer by subpoena or by discovery in the courts. The Joint Commission has mandated hospital peer review committees since 1952, and the federal government included language regarding peer-review protection in the Health Care Quality Improvement Act of 1986.

Every state has a law on the books, but the specifics and effectiveness of peer review will vary from state to state (see Florida’s Amendment 7, Kentucky, and Massachusetts). The whole idea is to allow for a process to evaluate physician practice or quality concerns without the fear of discovery or subsequent lawsuit. Even the act of referring a case to peer review is considered a confidential action in my state, so just the referral itself may not be discussed. So if you are referring to peer review, the answer is no, you cannot inform the patient’s PCP. HIPAA does not come into the picture here.

On the other hand, let’s assume, for sake of discussion, that you’ve heard a complaint (or several) about a certain hospitalist, Dr. Nogood. You could, if you desired, refer these complaints to peer review.

If so, then you are immediately bound by those rules of confidentiality. If you don’t refer the case, then you could inform the PCP that you have heard a complaint involving Dr. Nogood and that PCP’s patient.

I can’t see how that would violate HIPAA, because the PCP has an established relationship with that patient, and you might be only reporting facts (the complaint), not passing judgment on the quality of care. And I would not even go that far.

Why stop there? Why not tell that PCP exactly what you think of Dr. Nogood and his clinical practice, the details of the complaints against him, and how you think maybe that PCP should send his patients to someone else for better care? Well, you’re the CMO for the hospital. If you go beyond reporting facts and start reporting opinions, then you’ve just opened yourself up to accusations of restraint of trade by Dr. Nogood.

No matter what you may think of Dr. Nogood’s patient care, unless it falls outside the boundaries of acceptable practice (which can only be determined by a peer review committee), then you should not say anything.

Unless, of course, you want to be accused of spreading rumors, hearsay, and innuendo. Remember, we are talking about an independent practitioner, not a hospital employee.

Overall, it’s a bit of a sticky wicket. If you think the complaint has merit, then it should be sent to peer review—and you may speak no more of it. If you think the complaint is baseless, then why sustain it and tell the PCP?

Peer review is an exceptional process, and the physicians who serve on such committees perform a difficult and selfless service. We should all do our best to uphold its integrity.

Every morning at 8 a.m., a multidisciplinary team at Wayne Memorial Hospital in Honesdale, Pa., a rural pocket of about 5,000 people about 30 miles northeast of Scranton, gathers to discuss discharge planning. Representatives from social services, home health, nursing, physical therapy, pharmacy, and the HM group attend the meeting. Each stakeholder weighs in, listens to others, and voices concerns when applicable.

“We go through each patient in the morning, briefly, and go through the plan so that when there’s a discharge coming, everybody is on the same page and can try to get everything organized,” says Louis O’Boyle, DO, FACP, FHM, medical director of Advanced Inpatient Medicine, the hospitalist program contracted by Wayne Memorial, which has 98 acute-care beds. “The hospital has reminded us to be cognizant of getting that early discharge, and it’s become almost so rote now that we don’t even have to worry about it. It’s just a thing we do.”

Better bed management is a new mantra for hospitalists nationwide, because fewer open beds means fewer dollars for both the physician and the hospital. Better bed management also means improved patient satisfaction scores, as most patients would rather be at home (and those scores in the coming years will factor into Medicare reimbursement). And better bed management means reduced backlogs across the hospital, particularly “boarders” in the ED.

“The pressure really is on the hospital for a number of reasons,” says Ken Simone, DO, SFHM, president of Hospitalist and Practice Solutions in Veazie, Maine, and a member of Team Hospitalist. “In terms of reimbursement, the sooner they can get a patient out of the hospital, it opens bed space for patients in the emergency department. It eases up bottlenecks because the patient in the ED may not need the bed that is being opened, but they may need an ICU bed, and the ICU patient is stable enough to be transferred to that medical bed that you’re opening up. So it’s a domino effect, and it certainly helps with creating a better flow within the hospital.”

It sounds simple, of course: Discharge inpatients early in the day and fill that bed with another patient, akin to a busy restaurant flipping tables to reduce the line stretching out the front door. The more customers, the more money made—both for the restaurant (i.e. hospital) and the servers (i.e. providers). And the less potential customers wait, the happier they are with their service.

But adding new beds, at nearly $1 million per bed inclusive of the space, infrastructure, and technology, is unacceptable math for most U.S. hospitals struggling to make ends meet in a tough economy.¹ By contrast, an aggressive bed-management approach creates virtual bed capacity that creates more revenue-generating opportunities without those costs. And as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys tie patient satisfaction more directly to compensation, the more attention that will be focused on the discharge, as it will be the last process the patient experiences, and the one they likely will remember the most.

So if everyone agrees that discharging inpatients earlier in the day is a good idea, what’s the holdup? Interviews with more than a half-dozen hospitalists show a handful of factors that are present in all hospitals, large and small, academic and community:

• Downstream complications. HM is only one piece of the discharge puzzle. Hospitalists might be ready to discharge, but without that last test, or the ability to reach a pharmacist, the process slows. Even when discharge is complete, the room needs to be cleared and cleaned.
• Rounding protocols. Hospital-ists intuitively round on the sickest patients first, but that time-honored tradition has the byproduct of pushing those patients most likely to be sent home to the end of the line, automatically delaying discharges.
• Shift flexibility. Many hospitalist groups have morning shifts that begin at 8 a.m. Given the time it takes to craft discharge orders and deal with inevitable wrinkles in the process, that almost guarantees discharges will be pushed to later in the day.
• Hospital infrastructure. Insti-tutional bed management begins at the top, with a commitment across departments that discharge procedures are a shared priority. Without such across-the-board buy-in, the best hospitalists can do is fight against the tide. For example, a room could be vacated at 10 a.m., but housekeeping isn’t notified (or prepared) to clean the room for two hours because there is no institutional procedure in place to govern that decision.

“It’s harder than you think,” Dr. O’Boyle admits. “There are always extraneous factors that can delay the hospitalists from getting [discharges] done.”

Continued below...

Listen to AnnMarie Papp

Bed Management

Early-day discharge is just one pathway to improve “patient flow” and, therefore, bed management, according to a recent editorial in Health Affairs jointly penned by executives from the Institute for Healthcare Optimization in Newton, Mass., and the Institute for Healthcare Improvement in Cambridge, Mass.¹

Other techniques are:

• Reducing length of stay (LOS): Hospitalists have long focused on keeping patient stays at a minimum, although many researchers have argued that LOS can only be reduced to a point. Quality and patient safety issues in the Affordable Care Act might actually increase LOS, as hospitalists and other physicians work to reduce 30-day readmissions by ensuring everything is done right the first time.
• Expanding capacity: At an estimated cost of $1 million to add one new bed to a hospital, it is simply unlikely that institutions will be in a fiscal position to add physical beds in the next few years.
• Increasing staff: “Here again,” the authors state flatly, “pressures on hospital systems and operating margins make it unlikely that hospitals will dramatically increase their payrolls.”

No Consensus

Although a variety of techniques can help improve early day discharge, all have hurdles. Two of the most common suggestions are geographic rounding and discharge lounges. A third is the active bed-management (ABM) model that hospitalist Eric Howell, MD, SFHM, associate professor of medicine at Johns Hopkins University and director of Johns Hopkins Bayview Medical Center’s HM division, wrote about in the Annals of Internal Medicine in December 2008.²

Geographic rounding, also dubbed unit-based setups, can help improve bed management because all participants are co-located; however, the gains likely are not enough to motivate an institution to implement the model without demonstrated improvements to other systems as well, says John Nelson, MD, FACP, MHM, cofounder and past president of SHM and a principal in the practice management firm Nelson Flores Hospital Medicine Consultants.

Discharge lounges—areas usually administered by a nurse and billed as a place for patients to gather after they’ve been formally discharged but before they have arranged a ride to physically leave the hospital—have been adopted by many hospitals. Dr. Simone and others question the liability issues associated with keeping discharged patients under the watch of hospital staff and also wonder whether the setup can have a negative impact on patient satisfaction. (For more on discharge lounges, check out “Solution of Problem,” at www.the-hospitalist.org.)

If the hospitalist can push back and get this recognized as a hospital issue, that’s the only time when this problem can be solved. Hospitalists are a piece of the puzzle, but it’s not just them.

—David Bachman, MD, senior medical director for transitions of care, MaineHealth Clinical Integration, Portland, Maine

David Bachman, MD, senior medical director for transitions of care at MaineHealth Clinical Integration in Portland, Maine, and a former hospital administrator in New England, sees hospitalists as a lynchpin to the discharge process, but he also urges them to get the hospital to see them as “change agents” who need institutional support to make significant improvements.

“You’re trying to run cases through and it’s all dependent on downstream activity,” Dr. Bachman says. “If the hospitalist can push back and get this recognized as a hospital issue, that’s the only time when this problem can be solved. Hospitalists are a piece of the puzzle, but it’s not just them.”

Ideas to Chew On

Mitchell Wilson, MD, SFHM, chief medical officer for Eagle Hospital Physicians in Atlanta, agrees that reprioritizing physician rounds to encourage discharges would push patients out earlier, but he wants to see more physician assistants and nurse practitioners (PAs and NPs) blended into those rounds. The partnership would be a relatively simple and direct way for physicians to pass off nonclinical or less-intensive duties that afford them more time to focus on discharge planning. A dedicated nurse for HM service and the use of telemedicine could be folded into HM practices to help.

Listen to AnnMarie Papp

Listen to AnnMarie Papp

Each of the techniques would serve to get patients out earlier on what is arguably the most costly day of their stay. “Hospitals generally lose money on the last day of a patient’s stay,” Dr. Wilson says. “When appropriate from a patient care standpoint, discharging your patient and getting the bed ready for the next patient sooner is definitely an advantage for the hospital, and for the next patient.”

Dr. Bachman says one of the main hurdles to that process is no single provider “has clear responsibility and oversight. … It’s this diffuse responsibility.” That’s where Dr. Howell and colleagues thought ABM would work well. At Hopkins Bayview, hospitalists staffed an active bed-management program that rounded twice daily in ICUs and visited the ED regularly. The hospitalist on the 12-hour shift had no other duties, a luxury that HM pioneer Robert Wachter, MD, MHM, described at the time as “freeing him or her up to act as a full-time air traffic controller for all medical patients.”

The intervention reduced ED throughput for admitted patients by 98 minutes, to 360 minutes from 458 minutes. It also cut the amount of time the ED diverted ambulances because of overcrowding—the so-called “yellow alert”—by 6%, and the amount of time ambulances were diverted due to a lack of ICU beds—“red alert”—by 27%. Dr. Howell, an SHM board member, says the results showed how hospitalists can lead throughput change through institutions but that more work needs to be done to focus on early-day discharge.

“The hospital medicine side may be incentivized for early discharges,” he says, “but the hospital systems may not.”

Dr. Howell pushes for “2-by-10,” shorthand for identifying two patients daily who could be discharged by 10 a.m. because “the ED doesn’t necessarily need more beds for 24 hours. They need more beds early in the day.” But in keeping with the ABM model, Dr. Howell believes fiscal and personnel resources have to be dedicated to the problem to expect results. In the Hopkins Bayview intervention, Dr. Wachter, professor and associate chairman of the Department of Medicine at the University of California at San Francisco, chief of the division of hospital medicine, and chief of the medical service at UCSF Medical Center, estimated the annual costs of ABM at close to $1 million a year, given the likely need for four to six full-time equivalent hospitalists, according to a post on his Wachter’s World blog (www.wachtersworld. com) after the report was published.

One idea Dr. Howell suggests to push earlier discharges is restructuring physician workweeks, setting aside certain days for admission and certain days for follow-ups. If two shifts of follow-up days are scheduled after two days of admissions, it’s likely a hospitalist could follow a patient through their entire stay, he says. “You have to structure the doctor’s day to focus on discharges first,” he adds.

Dr. Howell also believes multidisciplinary rounds are key to earlier discharges. At Wayne Memorial Hospital and other places that have instituted such teams, discharge usually is just one byproduct of a construct ultimately aimed at quality improvement. Wayne Memorial’s Dr. O’Boyle says that since the team approach was initiated in September 2009, the hospital’s LOS has dropped by 0.75 days and patient satisfaction scores have risen about 25%. Those metrics will be key data points in the years to come as discharges and readmissions become tied to reimbursement via healthcare reform (see “Value-Based Purchasing Raises the Stakes,” May 2011).

Dr. Wilson

“One of the biggest factors for readmissions are things like pharmacy errors, and lack of follow-up, and other loose ends that, if you’re in too much of a hurry to get people out and you don’t have the whole team approach and make sure all your I’s are dotted and T’s are crossed, then they have an increased chance of coming back,” Dr. O’Boyle says. “So we focus on patient satisfaction, and we focus on the discharge day and the discharge time to prevent readmissions and to maximize patient satisfaction. That’s the bottom line for the hospital…It’s interesting how the bottom line seems to follow quality.”

Continued below...

Inherent Conflicts?

Early-day discharge actually can be a bad thing in some cases, Dr. Nelson says. Think of a case in which a patient might be ready for discharge in the late evening or during an overnight. To wait until the morning to send that patient home might not be the best approach.

The hospital has reminded us to be cognizant of getting that early discharge, and it’s become almost so rote now that we don’t even have to worry about it. It’s just a thing we do.

—Louis O’Boyle, DO, FACP, FHM, medical director, Advanced Inpatient Medicine, Honesdale, Pa.

“The place that manages length of stay most efficiently probably has plenty of late-day discharge,” he says.

Another potential conflict getting in the way of early-day discharge is what Dr. Wilson calls “admission competition.” For example, a hospitalist is working on discharge papers early in the morning but is then called away for a consult on an acute-care case in the ED or elsewhere. Each of the duties is important, but conflicting duties leave the hospitalist having to make choices.

“It’s not all straightforward,” Dr. Nelson says.

Emergency Nurses Association President AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, says that collaboration between nurses and physicians is an answer to such competition. Calling the problem a “wrinkle across the system,” Papa says that without hospital administrators taking point and declaring the issue of discharge a priority, little wholesale improvement will be made. Even then, physicians and nurses—as the two main groups interacting with the patient—have to work together, she adds.

“Hospitalists have to partner with nurses,” Papa says, imploring physicians and nurses to work together on discharge decisions. “If the physicians and nurses collaborate on the decision and plans of care for the patients and the care they’re giving them and the discharge instructions, then it’s a win-win for everybody.”

Richard Quinn is a freelance writer based in New Jersey.

Reference

1. Litvak E, Bisognano M. More patients, less payment: increasing hospital efficiency in the aftermath of health reform. Health Affairs. 2011;30(1): 76-80.
2. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Int Med. 2008;149(11):804-810.

Every morning at 8 a.m., a multidisciplinary team at Wayne Memorial Hospital in Honesdale, Pa., a rural pocket of about 5,000 people about 30 miles northeast of Scranton, gathers to discuss discharge planning. Representatives from social services, home health, nursing, physical therapy, pharmacy, and the HM group attend the meeting. Each stakeholder weighs in, listens to others, and voices concerns when applicable.

“We go through each patient in the morning, briefly, and go through the plan so that when there’s a discharge coming, everybody is on the same page and can try to get everything organized,” says Louis O’Boyle, DO, FACP, FHM, medical director of Advanced Inpatient Medicine, the hospitalist program contracted by Wayne Memorial, which has 98 acute-care beds. “The hospital has reminded us to be cognizant of getting that early discharge, and it’s become almost so rote now that we don’t even have to worry about it. It’s just a thing we do.”

Better bed management is a new mantra for hospitalists nationwide, because fewer open beds means fewer dollars for both the physician and the hospital. Better bed management also means improved patient satisfaction scores, as most patients would rather be at home (and those scores in the coming years will factor into Medicare reimbursement). And better bed management means reduced backlogs across the hospital, particularly “boarders” in the ED.

“The pressure really is on the hospital for a number of reasons,” says Ken Simone, DO, SFHM, president of Hospitalist and Practice Solutions in Veazie, Maine, and a member of Team Hospitalist. “In terms of reimbursement, the sooner they can get a patient out of the hospital, it opens bed space for patients in the emergency department. It eases up bottlenecks because the patient in the ED may not need the bed that is being opened, but they may need an ICU bed, and the ICU patient is stable enough to be transferred to that medical bed that you’re opening up. So it’s a domino effect, and it certainly helps with creating a better flow within the hospital.”

It sounds simple, of course: Discharge inpatients early in the day and fill that bed with another patient, akin to a busy restaurant flipping tables to reduce the line stretching out the front door. The more customers, the more money made—both for the restaurant (i.e. hospital) and the servers (i.e. providers). And the less potential customers wait, the happier they are with their service.

But adding new beds, at nearly $1 million per bed inclusive of the space, infrastructure, and technology, is unacceptable math for most U.S. hospitals struggling to make ends meet in a tough economy.¹ By contrast, an aggressive bed-management approach creates virtual bed capacity that creates more revenue-generating opportunities without those costs. And as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys tie patient satisfaction more directly to compensation, the more attention that will be focused on the discharge, as it will be the last process the patient experiences, and the one they likely will remember the most.

So if everyone agrees that discharging inpatients earlier in the day is a good idea, what’s the holdup? Interviews with more than a half-dozen hospitalists show a handful of factors that are present in all hospitals, large and small, academic and community:

• Downstream complications. HM is only one piece of the discharge puzzle. Hospitalists might be ready to discharge, but without that last test, or the ability to reach a pharmacist, the process slows. Even when discharge is complete, the room needs to be cleared and cleaned.
• Rounding protocols. Hospital-ists intuitively round on the sickest patients first, but that time-honored tradition has the byproduct of pushing those patients most likely to be sent home to the end of the line, automatically delaying discharges.
• Shift flexibility. Many hospitalist groups have morning shifts that begin at 8 a.m. Given the time it takes to craft discharge orders and deal with inevitable wrinkles in the process, that almost guarantees discharges will be pushed to later in the day.
• Hospital infrastructure. Insti-tutional bed management begins at the top, with a commitment across departments that discharge procedures are a shared priority. Without such across-the-board buy-in, the best hospitalists can do is fight against the tide. For example, a room could be vacated at 10 a.m., but housekeeping isn’t notified (or prepared) to clean the room for two hours because there is no institutional procedure in place to govern that decision.

“It’s harder than you think,” Dr. O’Boyle admits. “There are always extraneous factors that can delay the hospitalists from getting [discharges] done.”

Continued below...

Listen to AnnMarie Papp

Bed Management

Early-day discharge is just one pathway to improve “patient flow” and, therefore, bed management, according to a recent editorial in Health Affairs jointly penned by executives from the Institute for Healthcare Optimization in Newton, Mass., and the Institute for Healthcare Improvement in Cambridge, Mass.¹

Other techniques are:

• Reducing length of stay (LOS): Hospitalists have long focused on keeping patient stays at a minimum, although many researchers have argued that LOS can only be reduced to a point. Quality and patient safety issues in the Affordable Care Act might actually increase LOS, as hospitalists and other physicians work to reduce 30-day readmissions by ensuring everything is done right the first time.
• Expanding capacity: At an estimated cost of $1 million to add one new bed to a hospital, it is simply unlikely that institutions will be in a fiscal position to add physical beds in the next few years.
• Increasing staff: “Here again,” the authors state flatly, “pressures on hospital systems and operating margins make it unlikely that hospitals will dramatically increase their payrolls.”

No Consensus

Although a variety of techniques can help improve early day discharge, all have hurdles. Two of the most common suggestions are geographic rounding and discharge lounges. A third is the active bed-management (ABM) model that hospitalist Eric Howell, MD, SFHM, associate professor of medicine at Johns Hopkins University and director of Johns Hopkins Bayview Medical Center’s HM division, wrote about in the Annals of Internal Medicine in December 2008.²

Geographic rounding, also dubbed unit-based setups, can help improve bed management because all participants are co-located; however, the gains likely are not enough to motivate an institution to implement the model without demonstrated improvements to other systems as well, says John Nelson, MD, FACP, MHM, cofounder and past president of SHM and a principal in the practice management firm Nelson Flores Hospital Medicine Consultants.

Discharge lounges—areas usually administered by a nurse and billed as a place for patients to gather after they’ve been formally discharged but before they have arranged a ride to physically leave the hospital—have been adopted by many hospitals. Dr. Simone and others question the liability issues associated with keeping discharged patients under the watch of hospital staff and also wonder whether the setup can have a negative impact on patient satisfaction. (For more on discharge lounges, check out “Solution of Problem,” at www.the-hospitalist.org.)

If the hospitalist can push back and get this recognized as a hospital issue, that’s the only time when this problem can be solved. Hospitalists are a piece of the puzzle, but it’s not just them.

—David Bachman, MD, senior medical director for transitions of care, MaineHealth Clinical Integration, Portland, Maine

David Bachman, MD, senior medical director for transitions of care at MaineHealth Clinical Integration in Portland, Maine, and a former hospital administrator in New England, sees hospitalists as a lynchpin to the discharge process, but he also urges them to get the hospital to see them as “change agents” who need institutional support to make significant improvements.

“You’re trying to run cases through and it’s all dependent on downstream activity,” Dr. Bachman says. “If the hospitalist can push back and get this recognized as a hospital issue, that’s the only time when this problem can be solved. Hospitalists are a piece of the puzzle, but it’s not just them.”

Ideas to Chew On

Mitchell Wilson, MD, SFHM, chief medical officer for Eagle Hospital Physicians in Atlanta, agrees that reprioritizing physician rounds to encourage discharges would push patients out earlier, but he wants to see more physician assistants and nurse practitioners (PAs and NPs) blended into those rounds. The partnership would be a relatively simple and direct way for physicians to pass off nonclinical or less-intensive duties that afford them more time to focus on discharge planning. A dedicated nurse for HM service and the use of telemedicine could be folded into HM practices to help.

Listen to AnnMarie Papp

Listen to AnnMarie Papp

Each of the techniques would serve to get patients out earlier on what is arguably the most costly day of their stay. “Hospitals generally lose money on the last day of a patient’s stay,” Dr. Wilson says. “When appropriate from a patient care standpoint, discharging your patient and getting the bed ready for the next patient sooner is definitely an advantage for the hospital, and for the next patient.”

Dr. Bachman says one of the main hurdles to that process is no single provider “has clear responsibility and oversight. … It’s this diffuse responsibility.” That’s where Dr. Howell and colleagues thought ABM would work well. At Hopkins Bayview, hospitalists staffed an active bed-management program that rounded twice daily in ICUs and visited the ED regularly. The hospitalist on the 12-hour shift had no other duties, a luxury that HM pioneer Robert Wachter, MD, MHM, described at the time as “freeing him or her up to act as a full-time air traffic controller for all medical patients.”

The intervention reduced ED throughput for admitted patients by 98 minutes, to 360 minutes from 458 minutes. It also cut the amount of time the ED diverted ambulances because of overcrowding—the so-called “yellow alert”—by 6%, and the amount of time ambulances were diverted due to a lack of ICU beds—“red alert”—by 27%. Dr. Howell, an SHM board member, says the results showed how hospitalists can lead throughput change through institutions but that more work needs to be done to focus on early-day discharge.

“The hospital medicine side may be incentivized for early discharges,” he says, “but the hospital systems may not.”

Dr. Howell pushes for “2-by-10,” shorthand for identifying two patients daily who could be discharged by 10 a.m. because “the ED doesn’t necessarily need more beds for 24 hours. They need more beds early in the day.” But in keeping with the ABM model, Dr. Howell believes fiscal and personnel resources have to be dedicated to the problem to expect results. In the Hopkins Bayview intervention, Dr. Wachter, professor and associate chairman of the Department of Medicine at the University of California at San Francisco, chief of the division of hospital medicine, and chief of the medical service at UCSF Medical Center, estimated the annual costs of ABM at close to $1 million a year, given the likely need for four to six full-time equivalent hospitalists, according to a post on his Wachter’s World blog (www.wachtersworld. com) after the report was published.

One idea Dr. Howell suggests to push earlier discharges is restructuring physician workweeks, setting aside certain days for admission and certain days for follow-ups. If two shifts of follow-up days are scheduled after two days of admissions, it’s likely a hospitalist could follow a patient through their entire stay, he says. “You have to structure the doctor’s day to focus on discharges first,” he adds.

Dr. Howell also believes multidisciplinary rounds are key to earlier discharges. At Wayne Memorial Hospital and other places that have instituted such teams, discharge usually is just one byproduct of a construct ultimately aimed at quality improvement. Wayne Memorial’s Dr. O’Boyle says that since the team approach was initiated in September 2009, the hospital’s LOS has dropped by 0.75 days and patient satisfaction scores have risen about 25%. Those metrics will be key data points in the years to come as discharges and readmissions become tied to reimbursement via healthcare reform (see “Value-Based Purchasing Raises the Stakes,” May 2011).

Dr. Wilson

“One of the biggest factors for readmissions are things like pharmacy errors, and lack of follow-up, and other loose ends that, if you’re in too much of a hurry to get people out and you don’t have the whole team approach and make sure all your I’s are dotted and T’s are crossed, then they have an increased chance of coming back,” Dr. O’Boyle says. “So we focus on patient satisfaction, and we focus on the discharge day and the discharge time to prevent readmissions and to maximize patient satisfaction. That’s the bottom line for the hospital…It’s interesting how the bottom line seems to follow quality.”

Continued below...

Inherent Conflicts?

Early-day discharge actually can be a bad thing in some cases, Dr. Nelson says. Think of a case in which a patient might be ready for discharge in the late evening or during an overnight. To wait until the morning to send that patient home might not be the best approach.

The hospital has reminded us to be cognizant of getting that early discharge, and it’s become almost so rote now that we don’t even have to worry about it. It’s just a thing we do.

—Louis O’Boyle, DO, FACP, FHM, medical director, Advanced Inpatient Medicine, Honesdale, Pa.

“The place that manages length of stay most efficiently probably has plenty of late-day discharge,” he says.

Another potential conflict getting in the way of early-day discharge is what Dr. Wilson calls “admission competition.” For example, a hospitalist is working on discharge papers early in the morning but is then called away for a consult on an acute-care case in the ED or elsewhere. Each of the duties is important, but conflicting duties leave the hospitalist having to make choices.

“It’s not all straightforward,” Dr. Nelson says.

Emergency Nurses Association President AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, says that collaboration between nurses and physicians is an answer to such competition. Calling the problem a “wrinkle across the system,” Papa says that without hospital administrators taking point and declaring the issue of discharge a priority, little wholesale improvement will be made. Even then, physicians and nurses—as the two main groups interacting with the patient—have to work together, she adds.

“Hospitalists have to partner with nurses,” Papa says, imploring physicians and nurses to work together on discharge decisions. “If the physicians and nurses collaborate on the decision and plans of care for the patients and the care they’re giving them and the discharge instructions, then it’s a win-win for everybody.”

Richard Quinn is a freelance writer based in New Jersey.

Reference

1. Litvak E, Bisognano M. More patients, less payment: increasing hospital efficiency in the aftermath of health reform. Health Affairs. 2011;30(1): 76-80.
2. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Int Med. 2008;149(11):804-810.

Every morning at 8 a.m., a multidisciplinary team at Wayne Memorial Hospital in Honesdale, Pa., a rural pocket of about 5,000 people about 30 miles northeast of Scranton, gathers to discuss discharge planning. Representatives from social services, home health, nursing, physical therapy, pharmacy, and the HM group attend the meeting. Each stakeholder weighs in, listens to others, and voices concerns when applicable.

“We go through each patient in the morning, briefly, and go through the plan so that when there’s a discharge coming, everybody is on the same page and can try to get everything organized,” says Louis O’Boyle, DO, FACP, FHM, medical director of Advanced Inpatient Medicine, the hospitalist program contracted by Wayne Memorial, which has 98 acute-care beds. “The hospital has reminded us to be cognizant of getting that early discharge, and it’s become almost so rote now that we don’t even have to worry about it. It’s just a thing we do.”

Better bed management is a new mantra for hospitalists nationwide, because fewer open beds means fewer dollars for both the physician and the hospital. Better bed management also means improved patient satisfaction scores, as most patients would rather be at home (and those scores in the coming years will factor into Medicare reimbursement). And better bed management means reduced backlogs across the hospital, particularly “boarders” in the ED.

“The pressure really is on the hospital for a number of reasons,” says Ken Simone, DO, SFHM, president of Hospitalist and Practice Solutions in Veazie, Maine, and a member of Team Hospitalist. “In terms of reimbursement, the sooner they can get a patient out of the hospital, it opens bed space for patients in the emergency department. It eases up bottlenecks because the patient in the ED may not need the bed that is being opened, but they may need an ICU bed, and the ICU patient is stable enough to be transferred to that medical bed that you’re opening up. So it’s a domino effect, and it certainly helps with creating a better flow within the hospital.”

It sounds simple, of course: Discharge inpatients early in the day and fill that bed with another patient, akin to a busy restaurant flipping tables to reduce the line stretching out the front door. The more customers, the more money made—both for the restaurant (i.e. hospital) and the servers (i.e. providers). And the less potential customers wait, the happier they are with their service.

But adding new beds, at nearly $1 million per bed inclusive of the space, infrastructure, and technology, is unacceptable math for most U.S. hospitals struggling to make ends meet in a tough economy.¹ By contrast, an aggressive bed-management approach creates virtual bed capacity that creates more revenue-generating opportunities without those costs. And as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys tie patient satisfaction more directly to compensation, the more attention that will be focused on the discharge, as it will be the last process the patient experiences, and the one they likely will remember the most.

So if everyone agrees that discharging inpatients earlier in the day is a good idea, what’s the holdup? Interviews with more than a half-dozen hospitalists show a handful of factors that are present in all hospitals, large and small, academic and community:

• Downstream complications. HM is only one piece of the discharge puzzle. Hospitalists might be ready to discharge, but without that last test, or the ability to reach a pharmacist, the process slows. Even when discharge is complete, the room needs to be cleared and cleaned.
• Rounding protocols. Hospital-ists intuitively round on the sickest patients first, but that time-honored tradition has the byproduct of pushing those patients most likely to be sent home to the end of the line, automatically delaying discharges.
• Shift flexibility. Many hospitalist groups have morning shifts that begin at 8 a.m. Given the time it takes to craft discharge orders and deal with inevitable wrinkles in the process, that almost guarantees discharges will be pushed to later in the day.
• Hospital infrastructure. Insti-tutional bed management begins at the top, with a commitment across departments that discharge procedures are a shared priority. Without such across-the-board buy-in, the best hospitalists can do is fight against the tide. For example, a room could be vacated at 10 a.m., but housekeeping isn’t notified (or prepared) to clean the room for two hours because there is no institutional procedure in place to govern that decision.

“It’s harder than you think,” Dr. O’Boyle admits. “There are always extraneous factors that can delay the hospitalists from getting [discharges] done.”

Continued below...

Listen to AnnMarie Papp

Bed Management

Early-day discharge is just one pathway to improve “patient flow” and, therefore, bed management, according to a recent editorial in Health Affairs jointly penned by executives from the Institute for Healthcare Optimization in Newton, Mass., and the Institute for Healthcare Improvement in Cambridge, Mass.¹

Other techniques are:

• Reducing length of stay (LOS): Hospitalists have long focused on keeping patient stays at a minimum, although many researchers have argued that LOS can only be reduced to a point. Quality and patient safety issues in the Affordable Care Act might actually increase LOS, as hospitalists and other physicians work to reduce 30-day readmissions by ensuring everything is done right the first time.
• Expanding capacity: At an estimated cost of $1 million to add one new bed to a hospital, it is simply unlikely that institutions will be in a fiscal position to add physical beds in the next few years.
• Increasing staff: “Here again,” the authors state flatly, “pressures on hospital systems and operating margins make it unlikely that hospitals will dramatically increase their payrolls.”

No Consensus

Although a variety of techniques can help improve early day discharge, all have hurdles. Two of the most common suggestions are geographic rounding and discharge lounges. A third is the active bed-management (ABM) model that hospitalist Eric Howell, MD, SFHM, associate professor of medicine at Johns Hopkins University and director of Johns Hopkins Bayview Medical Center’s HM division, wrote about in the Annals of Internal Medicine in December 2008.²

Geographic rounding, also dubbed unit-based setups, can help improve bed management because all participants are co-located; however, the gains likely are not enough to motivate an institution to implement the model without demonstrated improvements to other systems as well, says John Nelson, MD, FACP, MHM, cofounder and past president of SHM and a principal in the practice management firm Nelson Flores Hospital Medicine Consultants.

Discharge lounges—areas usually administered by a nurse and billed as a place for patients to gather after they’ve been formally discharged but before they have arranged a ride to physically leave the hospital—have been adopted by many hospitals. Dr. Simone and others question the liability issues associated with keeping discharged patients under the watch of hospital staff and also wonder whether the setup can have a negative impact on patient satisfaction. (For more on discharge lounges, check out “Solution of Problem,” at www.the-hospitalist.org.)

If the hospitalist can push back and get this recognized as a hospital issue, that’s the only time when this problem can be solved. Hospitalists are a piece of the puzzle, but it’s not just them.

—David Bachman, MD, senior medical director for transitions of care, MaineHealth Clinical Integration, Portland, Maine

David Bachman, MD, senior medical director for transitions of care at MaineHealth Clinical Integration in Portland, Maine, and a former hospital administrator in New England, sees hospitalists as a lynchpin to the discharge process, but he also urges them to get the hospital to see them as “change agents” who need institutional support to make significant improvements.

“You’re trying to run cases through and it’s all dependent on downstream activity,” Dr. Bachman says. “If the hospitalist can push back and get this recognized as a hospital issue, that’s the only time when this problem can be solved. Hospitalists are a piece of the puzzle, but it’s not just them.”

Ideas to Chew On

Mitchell Wilson, MD, SFHM, chief medical officer for Eagle Hospital Physicians in Atlanta, agrees that reprioritizing physician rounds to encourage discharges would push patients out earlier, but he wants to see more physician assistants and nurse practitioners (PAs and NPs) blended into those rounds. The partnership would be a relatively simple and direct way for physicians to pass off nonclinical or less-intensive duties that afford them more time to focus on discharge planning. A dedicated nurse for HM service and the use of telemedicine could be folded into HM practices to help.

Listen to AnnMarie Papp

Listen to AnnMarie Papp

Each of the techniques would serve to get patients out earlier on what is arguably the most costly day of their stay. “Hospitals generally lose money on the last day of a patient’s stay,” Dr. Wilson says. “When appropriate from a patient care standpoint, discharging your patient and getting the bed ready for the next patient sooner is definitely an advantage for the hospital, and for the next patient.”

Dr. Bachman says one of the main hurdles to that process is no single provider “has clear responsibility and oversight. … It’s this diffuse responsibility.” That’s where Dr. Howell and colleagues thought ABM would work well. At Hopkins Bayview, hospitalists staffed an active bed-management program that rounded twice daily in ICUs and visited the ED regularly. The hospitalist on the 12-hour shift had no other duties, a luxury that HM pioneer Robert Wachter, MD, MHM, described at the time as “freeing him or her up to act as a full-time air traffic controller for all medical patients.”

The intervention reduced ED throughput for admitted patients by 98 minutes, to 360 minutes from 458 minutes. It also cut the amount of time the ED diverted ambulances because of overcrowding—the so-called “yellow alert”—by 6%, and the amount of time ambulances were diverted due to a lack of ICU beds—“red alert”—by 27%. Dr. Howell, an SHM board member, says the results showed how hospitalists can lead throughput change through institutions but that more work needs to be done to focus on early-day discharge.

“The hospital medicine side may be incentivized for early discharges,” he says, “but the hospital systems may not.”

Dr. Howell pushes for “2-by-10,” shorthand for identifying two patients daily who could be discharged by 10 a.m. because “the ED doesn’t necessarily need more beds for 24 hours. They need more beds early in the day.” But in keeping with the ABM model, Dr. Howell believes fiscal and personnel resources have to be dedicated to the problem to expect results. In the Hopkins Bayview intervention, Dr. Wachter, professor and associate chairman of the Department of Medicine at the University of California at San Francisco, chief of the division of hospital medicine, and chief of the medical service at UCSF Medical Center, estimated the annual costs of ABM at close to $1 million a year, given the likely need for four to six full-time equivalent hospitalists, according to a post on his Wachter’s World blog (www.wachtersworld. com) after the report was published.

One idea Dr. Howell suggests to push earlier discharges is restructuring physician workweeks, setting aside certain days for admission and certain days for follow-ups. If two shifts of follow-up days are scheduled after two days of admissions, it’s likely a hospitalist could follow a patient through their entire stay, he says. “You have to structure the doctor’s day to focus on discharges first,” he adds.

Dr. Howell also believes multidisciplinary rounds are key to earlier discharges. At Wayne Memorial Hospital and other places that have instituted such teams, discharge usually is just one byproduct of a construct ultimately aimed at quality improvement. Wayne Memorial’s Dr. O’Boyle says that since the team approach was initiated in September 2009, the hospital’s LOS has dropped by 0.75 days and patient satisfaction scores have risen about 25%. Those metrics will be key data points in the years to come as discharges and readmissions become tied to reimbursement via healthcare reform (see “Value-Based Purchasing Raises the Stakes,” May 2011).

Dr. Wilson

“One of the biggest factors for readmissions are things like pharmacy errors, and lack of follow-up, and other loose ends that, if you’re in too much of a hurry to get people out and you don’t have the whole team approach and make sure all your I’s are dotted and T’s are crossed, then they have an increased chance of coming back,” Dr. O’Boyle says. “So we focus on patient satisfaction, and we focus on the discharge day and the discharge time to prevent readmissions and to maximize patient satisfaction. That’s the bottom line for the hospital…It’s interesting how the bottom line seems to follow quality.”

Continued below...

Inherent Conflicts?

Early-day discharge actually can be a bad thing in some cases, Dr. Nelson says. Think of a case in which a patient might be ready for discharge in the late evening or during an overnight. To wait until the morning to send that patient home might not be the best approach.

The hospital has reminded us to be cognizant of getting that early discharge, and it’s become almost so rote now that we don’t even have to worry about it. It’s just a thing we do.

—Louis O’Boyle, DO, FACP, FHM, medical director, Advanced Inpatient Medicine, Honesdale, Pa.

“The place that manages length of stay most efficiently probably has plenty of late-day discharge,” he says.

Another potential conflict getting in the way of early-day discharge is what Dr. Wilson calls “admission competition.” For example, a hospitalist is working on discharge papers early in the morning but is then called away for a consult on an acute-care case in the ED or elsewhere. Each of the duties is important, but conflicting duties leave the hospitalist having to make choices.

“It’s not all straightforward,” Dr. Nelson says.

Emergency Nurses Association President AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, says that collaboration between nurses and physicians is an answer to such competition. Calling the problem a “wrinkle across the system,” Papa says that without hospital administrators taking point and declaring the issue of discharge a priority, little wholesale improvement will be made. Even then, physicians and nurses—as the two main groups interacting with the patient—have to work together, she adds.

“Hospitalists have to partner with nurses,” Papa says, imploring physicians and nurses to work together on discharge decisions. “If the physicians and nurses collaborate on the decision and plans of care for the patients and the care they’re giving them and the discharge instructions, then it’s a win-win for everybody.”

Richard Quinn is a freelance writer based in New Jersey.

Reference

1. Litvak E, Bisognano M. More patients, less payment: increasing hospital efficiency in the aftermath of health reform. Health Affairs. 2011;30(1): 76-80.
2. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S. Active bed management by hospitalists and emergency department throughput. Ann Int Med. 2008;149(11):804-810.

Those of you who are familiar with Medical Group Management Association’s reports know that MGMA uses medical group “ownership” categories that are similar to, but slightly different from, the employment model categories historically utilized by SHM. This year, we added the question: “Is your practice part of a multistate hospitalist group or management company?” to the SHM-MGMA Hospital Medicine Supplement. This question enables us to crosswalk from MGMA’s ownership categories to SHM’s traditional employment categories:

• Employed by a hospital or integrated delivery system;
• Employed by a multistate hospitalist group or management company;
• Employed by an independent multispecialty or primary-care medical group;
• Employed by an independent hospitalist-only group;
• Employed by an academic entity; and
• Employed by other.

The blue columns in the chart below show median annual direct compensation (light blue) and retirement benefits (dark blue) for all adult hospitalists by employment model, including the data for academic internal medicine hospitalists from the separate SHM-MGMA academic survey conducted in the fall of 2010.¹ The median ratio of compensation to work RVUs for each employment type is represented by red squares.

Academic hospitalists report the lowest compensation but the highest compensation per unit of clinical work, even when production data is standardized to 100% billable clinical time.

click for large version

“For most academic hospitalists, teaching and supervising residents is an integral part of our clinical work; this probably impedes our clinical efficiency relative to non-academicians,” explains Grace Huang, MD, a member of SHM’s Practice Analysis Committee (PAC). “On weekends, when only half the residents are present and I don’t spend as much time teaching, I can see two to three times more patients.”

Independent hospitalist-only groups saw both the highest direct compensation and the highest compensation per unit of work, while hospitalists employed by multistate groups and management companies had the second-lowest overall direct compensation and the lowest compensation per wRVU.

When including the value of employer retirement plan contributions, however, hospitalists employed by management companies received a combined total remuneration that was higher than for hospitalists employed by hospitals or “other” employers.

“If I’m a hospitalist working for a multistate group, I want to know I’m getting something good that I might not get working for a hospital,” says PAC member Troy Ahlstrom, MD, SFHM. “A better retirement contribution is an obvious example; a hospital can’t afford to give a high-powered retirement plan to all 5,000-plus employees, while a physician company with all ‘highly compensated’ employees can. It’s a perk of working for an independent company.”

Multispecialty/primary-care medical groups and independent hospitalist-only groups provided the highest direct compensation and total remuneration (including retirement contributions). “Keep in mind, though, that they have different responsibilities that come with the money,” Dr. Ahlstrom says. “Hospitalists in local groups have more management responsibilities and more ownership risk, so they should make more for the extra work of running a business. Hospitalists in multispecialty groups have the benefit of an investment in their salaries by their colleagues, but they also have to answer directly to their colleagues for the privilege.”

Leslie Flores, SHM senior advisor, practice management

Reference

1. MGMA’s Academic Practice Compensation and Production Survey for Faculty and Management. Medical Group Management Association website. Available at: www.mgma.com. Accessed Aug. 31, 2011.

Academic Hospitalists Gear Up for Learning

The challenges of academic HM are different from other sectors of the specialty. Academic hospitalists, division chiefs, and administrators at academic teaching hospitals contend with the pressure of receiving grants, presenting at grand rounds, and reserving time for research and educational projects.

While it can be overwhelming, especially for academic hospitalists early in their careers, the Academic Hospitalist Academy helps untangle those challenges and turn them into long-term professional opportunities. Hosted jointly by SHM, the Society of General Internal Medicine (SGIM), and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM), the academy is a three-day course dedicated to education, scholarship, and professional success for academic hospitalists.

In addition to helping them become better hospitalists, Academic Hospitalist Academy uses didactic sessions, small-group exercises, and other interactive techniques to help academic hospitalists become better teachers, create and publish scholarly work, and get first in line for promotions.

Now in its third year, Academic Hospitalist Academy is consistently met with rave reviews from attendees. According to evaluations from the 2010 academy, attendees unanimously felt the course was worth their time and money; 99% said they would recommend it to a colleague.

Those of you who are familiar with Medical Group Management Association’s reports know that MGMA uses medical group “ownership” categories that are similar to, but slightly different from, the employment model categories historically utilized by SHM. This year, we added the question: “Is your practice part of a multistate hospitalist group or management company?” to the SHM-MGMA Hospital Medicine Supplement. This question enables us to crosswalk from MGMA’s ownership categories to SHM’s traditional employment categories:

• Employed by a hospital or integrated delivery system;
• Employed by a multistate hospitalist group or management company;
• Employed by an independent multispecialty or primary-care medical group;
• Employed by an independent hospitalist-only group;
• Employed by an academic entity; and
• Employed by other.

The blue columns in the chart below show median annual direct compensation (light blue) and retirement benefits (dark blue) for all adult hospitalists by employment model, including the data for academic internal medicine hospitalists from the separate SHM-MGMA academic survey conducted in the fall of 2010.¹ The median ratio of compensation to work RVUs for each employment type is represented by red squares.

Academic hospitalists report the lowest compensation but the highest compensation per unit of clinical work, even when production data is standardized to 100% billable clinical time.

click for large version

“For most academic hospitalists, teaching and supervising residents is an integral part of our clinical work; this probably impedes our clinical efficiency relative to non-academicians,” explains Grace Huang, MD, a member of SHM’s Practice Analysis Committee (PAC). “On weekends, when only half the residents are present and I don’t spend as much time teaching, I can see two to three times more patients.”

Independent hospitalist-only groups saw both the highest direct compensation and the highest compensation per unit of work, while hospitalists employed by multistate groups and management companies had the second-lowest overall direct compensation and the lowest compensation per wRVU.

When including the value of employer retirement plan contributions, however, hospitalists employed by management companies received a combined total remuneration that was higher than for hospitalists employed by hospitals or “other” employers.

“If I’m a hospitalist working for a multistate group, I want to know I’m getting something good that I might not get working for a hospital,” says PAC member Troy Ahlstrom, MD, SFHM. “A better retirement contribution is an obvious example; a hospital can’t afford to give a high-powered retirement plan to all 5,000-plus employees, while a physician company with all ‘highly compensated’ employees can. It’s a perk of working for an independent company.”

Multispecialty/primary-care medical groups and independent hospitalist-only groups provided the highest direct compensation and total remuneration (including retirement contributions). “Keep in mind, though, that they have different responsibilities that come with the money,” Dr. Ahlstrom says. “Hospitalists in local groups have more management responsibilities and more ownership risk, so they should make more for the extra work of running a business. Hospitalists in multispecialty groups have the benefit of an investment in their salaries by their colleagues, but they also have to answer directly to their colleagues for the privilege.”

Leslie Flores, SHM senior advisor, practice management

Reference

1. MGMA’s Academic Practice Compensation and Production Survey for Faculty and Management. Medical Group Management Association website. Available at: www.mgma.com. Accessed Aug. 31, 2011.

Academic Hospitalists Gear Up for Learning

The challenges of academic HM are different from other sectors of the specialty. Academic hospitalists, division chiefs, and administrators at academic teaching hospitals contend with the pressure of receiving grants, presenting at grand rounds, and reserving time for research and educational projects.

While it can be overwhelming, especially for academic hospitalists early in their careers, the Academic Hospitalist Academy helps untangle those challenges and turn them into long-term professional opportunities. Hosted jointly by SHM, the Society of General Internal Medicine (SGIM), and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM), the academy is a three-day course dedicated to education, scholarship, and professional success for academic hospitalists.

In addition to helping them become better hospitalists, Academic Hospitalist Academy uses didactic sessions, small-group exercises, and other interactive techniques to help academic hospitalists become better teachers, create and publish scholarly work, and get first in line for promotions.

Now in its third year, Academic Hospitalist Academy is consistently met with rave reviews from attendees. According to evaluations from the 2010 academy, attendees unanimously felt the course was worth their time and money; 99% said they would recommend it to a colleague.

Those of you who are familiar with Medical Group Management Association’s reports know that MGMA uses medical group “ownership” categories that are similar to, but slightly different from, the employment model categories historically utilized by SHM. This year, we added the question: “Is your practice part of a multistate hospitalist group or management company?” to the SHM-MGMA Hospital Medicine Supplement. This question enables us to crosswalk from MGMA’s ownership categories to SHM’s traditional employment categories:

• Employed by a hospital or integrated delivery system;
• Employed by a multistate hospitalist group or management company;
• Employed by an independent multispecialty or primary-care medical group;
• Employed by an independent hospitalist-only group;
• Employed by an academic entity; and
• Employed by other.

The blue columns in the chart below show median annual direct compensation (light blue) and retirement benefits (dark blue) for all adult hospitalists by employment model, including the data for academic internal medicine hospitalists from the separate SHM-MGMA academic survey conducted in the fall of 2010.¹ The median ratio of compensation to work RVUs for each employment type is represented by red squares.

Academic hospitalists report the lowest compensation but the highest compensation per unit of clinical work, even when production data is standardized to 100% billable clinical time.

click for large version

“For most academic hospitalists, teaching and supervising residents is an integral part of our clinical work; this probably impedes our clinical efficiency relative to non-academicians,” explains Grace Huang, MD, a member of SHM’s Practice Analysis Committee (PAC). “On weekends, when only half the residents are present and I don’t spend as much time teaching, I can see two to three times more patients.”

Independent hospitalist-only groups saw both the highest direct compensation and the highest compensation per unit of work, while hospitalists employed by multistate groups and management companies had the second-lowest overall direct compensation and the lowest compensation per wRVU.

When including the value of employer retirement plan contributions, however, hospitalists employed by management companies received a combined total remuneration that was higher than for hospitalists employed by hospitals or “other” employers.

“If I’m a hospitalist working for a multistate group, I want to know I’m getting something good that I might not get working for a hospital,” says PAC member Troy Ahlstrom, MD, SFHM. “A better retirement contribution is an obvious example; a hospital can’t afford to give a high-powered retirement plan to all 5,000-plus employees, while a physician company with all ‘highly compensated’ employees can. It’s a perk of working for an independent company.”

Multispecialty/primary-care medical groups and independent hospitalist-only groups provided the highest direct compensation and total remuneration (including retirement contributions). “Keep in mind, though, that they have different responsibilities that come with the money,” Dr. Ahlstrom says. “Hospitalists in local groups have more management responsibilities and more ownership risk, so they should make more for the extra work of running a business. Hospitalists in multispecialty groups have the benefit of an investment in their salaries by their colleagues, but they also have to answer directly to their colleagues for the privilege.”

Leslie Flores, SHM senior advisor, practice management

Reference

1. MGMA’s Academic Practice Compensation and Production Survey for Faculty and Management. Medical Group Management Association website. Available at: www.mgma.com. Accessed Aug. 31, 2011.

Academic Hospitalists Gear Up for Learning

The challenges of academic HM are different from other sectors of the specialty. Academic hospitalists, division chiefs, and administrators at academic teaching hospitals contend with the pressure of receiving grants, presenting at grand rounds, and reserving time for research and educational projects.

While it can be overwhelming, especially for academic hospitalists early in their careers, the Academic Hospitalist Academy helps untangle those challenges and turn them into long-term professional opportunities. Hosted jointly by SHM, the Society of General Internal Medicine (SGIM), and the Association of Chiefs and Leaders of General Internal Medicine (ACLGIM), the academy is a three-day course dedicated to education, scholarship, and professional success for academic hospitalists.

In addition to helping them become better hospitalists, Academic Hospitalist Academy uses didactic sessions, small-group exercises, and other interactive techniques to help academic hospitalists become better teachers, create and publish scholarly work, and get first in line for promotions.

Now in its third year, Academic Hospitalist Academy is consistently met with rave reviews from attendees. According to evaluations from the 2010 academy, attendees unanimously felt the course was worth their time and money; 99% said they would recommend it to a colleague.

Each visit category and level of service has corresponding documentation requirements.¹ Selecting an evaluation and management (E/M) level is based upon 1) the content of the three “key” components: history, exam, and decision-making, or 2) time, but only when counseling or coordination of care dominates more than 50% of the physician’s total visit time. Failure to document any essential element in a given visit level (e.g. family history required but missing for 99222 and 99223) could result in downcoding or service denial. Be aware of what an auditor expects when reviewing the key component of “history.”

Documentation Options

Auditors recognize two sets of documentation guidelines: “1995” and “1997” guidelines.^2,3,4 Each set of guidelines has received valid criticism. The 1995 guidelines undoubtedly are vague and subjective in some areas, whereas the 1997 guidelines are known for arduous specificity.

However, to benefit all physicians and specialties, both sets of guidelines apply to visit-level selection. In other words, physicians can utilize either set when documenting their services, and auditors must review provider records against both styles. The final audited outcome reflects the highest visit level supported upon comparison.

click for large version

Elements of History^2,3,4

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

History of present illness (HPI). The HPI is a description of the patient’s present illness as it developed. It characteristically is referenced as location, quality, severity, timing, context, modifying factors, and associated signs/symptoms, as related to the chief complaint. The 1997 guidelines allow physicians to receive HPI credit for providing the status of the patient’s chronic or inactive conditions, such as “extrinsic asthma without acute exacerbation in past six months.” An auditor will not assign HPI credit to a chronic or inactive condition that does not have a corresponding status (e.g. “asthma”). This will be considered “past medical history.”

The HPI is classified as brief (a comment on <3 HPI elements, or the status of <2 conditions) or extended (a comment on >4 HPI elements, or the status of >3 conditions). Consider these examples of an extended HPI:

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

Physicians receive credit for confirming and personally documenting the HPI, or linking to documentation recorded by residents (residents, fellows, interns) or nonphysician providers (NPPs) when performing services according to the Teaching Physician Rules or Split-Shared Billing Rules, respectively. An auditor will not assign physician credit for HPI elements documented by ancillary staff (registered nurses, medical assistants) or students.

click for large version

Review of systems (ROS). The ROS is a series of questions used to elicit information about additional signs, symptoms, or problems currently or previously experienced by the patient: constitutional; eyes, ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/ lymphatic; and allergic/immunologic. Auditors classify the ROS as brief (a comment on one system), extended (a comment on two to nine systems), or complete (a comment on >10 systems). Physicians can document a complete ROS by noting individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal); and occasional runny nose (ears, nose, mouth, throat),” or by eliciting a complete system review but documenting only the positive and pertinent negative findings related to the chief complaint, along with an additional comment that “all other systems are negative.”

Although the latter method is formally included in Medicare’s documentation guidelines and accepted by some Medicare contractors (e.g. Highmark, WPS), be aware that it is not universally accepted.^5,6

Documentation involving the ROS can be provided by anyone, including the patient. The physician should reference ROS information that is completed by individuals other than residents or NPPs during services provided under the Teaching Physician Rules or Split-Shared Billing Rules. Physician duplication of ROS information is unnecessary unless an update or revision is required.

Past, family, and social history (PFSH). The PFSH involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. The PFSH could be classified as pertinent (a comment on one history) or complete (a comment in each of the three histories). The physician merely needs a single comment associated with each history for the PFSH to be regarded as complete. Refrain from using “noncontributory” to describe any of the histories, as previous misuse of this term has resulted in its prohibition. An example of a complete PFSH documentation includes: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s esophagus; no tobacco or alcohol use.”

Similar to the ROS, PFSH documentation can be provided by anyone, including the patient, and the physician should reference the documented PFSH in his own progress note. Redocumentation of the PFSH is not necessary unless a revision is required.

PFSH documentation is only required for initial care services (i.e. initial hospital care, initial observation care, consultations). It is not warranted in subsequent care services unless additional, pertinent information is obtained during the hospital stay that impacts care.

Considerations

When a physician cannot elicit historical information from the patient directly, and no other source is available, they should document “unable to obtain” the history. A comment regarding the circumstances surrounding this problem (e.g. patient confused, no caregiver present) should be provided, along with the available information from the limited resources (e.g. emergency medical technicians, previous hospitalizations at the same facility). Some contractors will not penalize the physician for the inability to ascertain complete historical information, as long as a proven attempt to obtain the information is evident.

Never document any item for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

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

References

1. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2010. Northbrook, IL: American College of Chest Physicians, 2009; 87-118.
2. Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. CMS website. Available at: www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf. Accessed July 7, 2011.
3. Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. CMS website. Available at: http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed July 7, 2011.
4. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011.
5. History of E/M (Q&As). WPS Health Insurance website. Available at: http://www.wpsmedicare.com/j5macpartb/resources/provider_types/2009_0526_emqahistory.shtml. Accessed July 11, 2011.
6. Frequently Asked Questions: Evaluation and Management Services (Part B). Highmark Medicare Services website. Available at: www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed on July 11, 2011.

Each visit category and level of service has corresponding documentation requirements.¹ Selecting an evaluation and management (E/M) level is based upon 1) the content of the three “key” components: history, exam, and decision-making, or 2) time, but only when counseling or coordination of care dominates more than 50% of the physician’s total visit time. Failure to document any essential element in a given visit level (e.g. family history required but missing for 99222 and 99223) could result in downcoding or service denial. Be aware of what an auditor expects when reviewing the key component of “history.”

Documentation Options

Auditors recognize two sets of documentation guidelines: “1995” and “1997” guidelines.^2,3,4 Each set of guidelines has received valid criticism. The 1995 guidelines undoubtedly are vague and subjective in some areas, whereas the 1997 guidelines are known for arduous specificity.

However, to benefit all physicians and specialties, both sets of guidelines apply to visit-level selection. In other words, physicians can utilize either set when documenting their services, and auditors must review provider records against both styles. The final audited outcome reflects the highest visit level supported upon comparison.

click for large version

Elements of History^2,3,4

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

History of present illness (HPI). The HPI is a description of the patient’s present illness as it developed. It characteristically is referenced as location, quality, severity, timing, context, modifying factors, and associated signs/symptoms, as related to the chief complaint. The 1997 guidelines allow physicians to receive HPI credit for providing the status of the patient’s chronic or inactive conditions, such as “extrinsic asthma without acute exacerbation in past six months.” An auditor will not assign HPI credit to a chronic or inactive condition that does not have a corresponding status (e.g. “asthma”). This will be considered “past medical history.”

The HPI is classified as brief (a comment on <3 HPI elements, or the status of <2 conditions) or extended (a comment on >4 HPI elements, or the status of >3 conditions). Consider these examples of an extended HPI:

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

Physicians receive credit for confirming and personally documenting the HPI, or linking to documentation recorded by residents (residents, fellows, interns) or nonphysician providers (NPPs) when performing services according to the Teaching Physician Rules or Split-Shared Billing Rules, respectively. An auditor will not assign physician credit for HPI elements documented by ancillary staff (registered nurses, medical assistants) or students.

click for large version

Review of systems (ROS). The ROS is a series of questions used to elicit information about additional signs, symptoms, or problems currently or previously experienced by the patient: constitutional; eyes, ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/ lymphatic; and allergic/immunologic. Auditors classify the ROS as brief (a comment on one system), extended (a comment on two to nine systems), or complete (a comment on >10 systems). Physicians can document a complete ROS by noting individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal); and occasional runny nose (ears, nose, mouth, throat),” or by eliciting a complete system review but documenting only the positive and pertinent negative findings related to the chief complaint, along with an additional comment that “all other systems are negative.”

Although the latter method is formally included in Medicare’s documentation guidelines and accepted by some Medicare contractors (e.g. Highmark, WPS), be aware that it is not universally accepted.^5,6

Documentation involving the ROS can be provided by anyone, including the patient. The physician should reference ROS information that is completed by individuals other than residents or NPPs during services provided under the Teaching Physician Rules or Split-Shared Billing Rules. Physician duplication of ROS information is unnecessary unless an update or revision is required.

Past, family, and social history (PFSH). The PFSH involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. The PFSH could be classified as pertinent (a comment on one history) or complete (a comment in each of the three histories). The physician merely needs a single comment associated with each history for the PFSH to be regarded as complete. Refrain from using “noncontributory” to describe any of the histories, as previous misuse of this term has resulted in its prohibition. An example of a complete PFSH documentation includes: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s esophagus; no tobacco or alcohol use.”

Similar to the ROS, PFSH documentation can be provided by anyone, including the patient, and the physician should reference the documented PFSH in his own progress note. Redocumentation of the PFSH is not necessary unless a revision is required.

PFSH documentation is only required for initial care services (i.e. initial hospital care, initial observation care, consultations). It is not warranted in subsequent care services unless additional, pertinent information is obtained during the hospital stay that impacts care.

Considerations

When a physician cannot elicit historical information from the patient directly, and no other source is available, they should document “unable to obtain” the history. A comment regarding the circumstances surrounding this problem (e.g. patient confused, no caregiver present) should be provided, along with the available information from the limited resources (e.g. emergency medical technicians, previous hospitalizations at the same facility). Some contractors will not penalize the physician for the inability to ascertain complete historical information, as long as a proven attempt to obtain the information is evident.

Never document any item for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

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

References

1. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2010. Northbrook, IL: American College of Chest Physicians, 2009; 87-118.
2. Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. CMS website. Available at: www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf. Accessed July 7, 2011.
3. Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. CMS website. Available at: http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed July 7, 2011.
4. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011.
5. History of E/M (Q&As). WPS Health Insurance website. Available at: http://www.wpsmedicare.com/j5macpartb/resources/provider_types/2009_0526_emqahistory.shtml. Accessed July 11, 2011.
6. Frequently Asked Questions: Evaluation and Management Services (Part B). Highmark Medicare Services website. Available at: www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed on July 11, 2011.

Each visit category and level of service has corresponding documentation requirements.¹ Selecting an evaluation and management (E/M) level is based upon 1) the content of the three “key” components: history, exam, and decision-making, or 2) time, but only when counseling or coordination of care dominates more than 50% of the physician’s total visit time. Failure to document any essential element in a given visit level (e.g. family history required but missing for 99222 and 99223) could result in downcoding or service denial. Be aware of what an auditor expects when reviewing the key component of “history.”

Documentation Options

Auditors recognize two sets of documentation guidelines: “1995” and “1997” guidelines.^2,3,4 Each set of guidelines has received valid criticism. The 1995 guidelines undoubtedly are vague and subjective in some areas, whereas the 1997 guidelines are known for arduous specificity.

However, to benefit all physicians and specialties, both sets of guidelines apply to visit-level selection. In other words, physicians can utilize either set when documenting their services, and auditors must review provider records against both styles. The final audited outcome reflects the highest visit level supported upon comparison.

click for large version

Elements of History^2,3,4

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

History of present illness (HPI). The HPI is a description of the patient’s present illness as it developed. It characteristically is referenced as location, quality, severity, timing, context, modifying factors, and associated signs/symptoms, as related to the chief complaint. The 1997 guidelines allow physicians to receive HPI credit for providing the status of the patient’s chronic or inactive conditions, such as “extrinsic asthma without acute exacerbation in past six months.” An auditor will not assign HPI credit to a chronic or inactive condition that does not have a corresponding status (e.g. “asthma”). This will be considered “past medical history.”

The HPI is classified as brief (a comment on <3 HPI elements, or the status of <2 conditions) or extended (a comment on >4 HPI elements, or the status of >3 conditions). Consider these examples of an extended HPI:

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

Physicians receive credit for confirming and personally documenting the HPI, or linking to documentation recorded by residents (residents, fellows, interns) or nonphysician providers (NPPs) when performing services according to the Teaching Physician Rules or Split-Shared Billing Rules, respectively. An auditor will not assign physician credit for HPI elements documented by ancillary staff (registered nurses, medical assistants) or students.

click for large version

Review of systems (ROS). The ROS is a series of questions used to elicit information about additional signs, symptoms, or problems currently or previously experienced by the patient: constitutional; eyes, ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/ lymphatic; and allergic/immunologic. Auditors classify the ROS as brief (a comment on one system), extended (a comment on two to nine systems), or complete (a comment on >10 systems). Physicians can document a complete ROS by noting individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal); and occasional runny nose (ears, nose, mouth, throat),” or by eliciting a complete system review but documenting only the positive and pertinent negative findings related to the chief complaint, along with an additional comment that “all other systems are negative.”

Although the latter method is formally included in Medicare’s documentation guidelines and accepted by some Medicare contractors (e.g. Highmark, WPS), be aware that it is not universally accepted.^5,6

Documentation involving the ROS can be provided by anyone, including the patient. The physician should reference ROS information that is completed by individuals other than residents or NPPs during services provided under the Teaching Physician Rules or Split-Shared Billing Rules. Physician duplication of ROS information is unnecessary unless an update or revision is required.

Past, family, and social history (PFSH). The PFSH involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. The PFSH could be classified as pertinent (a comment on one history) or complete (a comment in each of the three histories). The physician merely needs a single comment associated with each history for the PFSH to be regarded as complete. Refrain from using “noncontributory” to describe any of the histories, as previous misuse of this term has resulted in its prohibition. An example of a complete PFSH documentation includes: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s esophagus; no tobacco or alcohol use.”

Similar to the ROS, PFSH documentation can be provided by anyone, including the patient, and the physician should reference the documented PFSH in his own progress note. Redocumentation of the PFSH is not necessary unless a revision is required.

PFSH documentation is only required for initial care services (i.e. initial hospital care, initial observation care, consultations). It is not warranted in subsequent care services unless additional, pertinent information is obtained during the hospital stay that impacts care.

Considerations

When a physician cannot elicit historical information from the patient directly, and no other source is available, they should document “unable to obtain” the history. A comment regarding the circumstances surrounding this problem (e.g. patient confused, no caregiver present) should be provided, along with the available information from the limited resources (e.g. emergency medical technicians, previous hospitalizations at the same facility). Some contractors will not penalize the physician for the inability to ascertain complete historical information, as long as a proven attempt to obtain the information is evident.

Never document any item for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

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

References

1. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2010. Northbrook, IL: American College of Chest Physicians, 2009; 87-118.
2. Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. CMS website. Available at: www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf. Accessed July 7, 2011.
3. Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. CMS website. Available at: http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed July 7, 2011.
4. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011.
5. History of E/M (Q&As). WPS Health Insurance website. Available at: http://www.wpsmedicare.com/j5macpartb/resources/provider_types/2009_0526_emqahistory.shtml. Accessed July 11, 2011.
6. Frequently Asked Questions: Evaluation and Management Services (Part B). Highmark Medicare Services website. Available at: www.highmarkmedicareservices.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed on July 11, 2011.

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality.

I suspect most of you have reviewed the study or at least heard about it. Bob Wachter, MD, MHM, blogged about the study. An article about the study appeared in American Medical Association News. Even National Public Radio ran a piece about the study on their show “Morning Edition.”

I am, of course, referring to the study by Kuo and Goodwin, which was published in the Annals of Internal Medicine in early August.¹

In this study, the authors looked at a sample of patients (5%) with primary-care physicians (PCPs) enrolled in Medicare who were cared for by their PCP or a hospitalist during a period from 2001 to 2006. The authors stated their underlying hypotheses as:

• Hospitalist care would be associated with costs shifting from the hospital to the post-hospital setting;
• Hospitalist care would be associated with a decrease in discharges directly to home; and
• Discontinuities of care associated with hospitalist care would lead to a greater rate of visits to the emergency room and readmissions to the hospital, resulting in increased Medicare costs.

Did the authors say hospitalist care cost more? They can’t possibly be correct, can they? Don’t all the hospitalist studies show that hospitalists provide the same quality of care as primary-care doctors, except the costs are lower and the hospital length of stay (LOS) is shorter when hospitalists care for patients?

The point here is that these investigators look at the care not only during a patient’s hospital stay, but also for 30 days after discharge. This is something that had not been done previously—at least not on this scale.

Focus on Facts

And what did the authors find? Patients cared for by hospitalists, as compared to their PCPs, had a shorter LOS and lower in-hospital costs, but these patients also were less likely to be discharged directly to home, less likely to see their PCPs post-discharge, and had more hospital readmissions, ED visits, and nursing home visits after discharge.

Since its release two months ago, I have heard a lot of discussion about the study. Here are a few of the comments I’ve heard:

• “This was an observational study. You can’t possibly remove all confounders in an observational study.”
• “The authors looked at a time period early in the hospitalist movement. If they did the study today, the results would be different.”
• “The additional costs hospitalists incurred were only $50 per patient. Wouldn’t you pay $50 more if the care was better?”
• “This is why hospitals hired hospitalists. They save money for the hospitals. What did they expect to find?”

I agree that observational studies have limitations (even the authors acknowledged this), but this doesn’t mean results from observational studies are invalid. Some of us don’t want to hear this, but this actually was a pretty well-done study with a robust statistical analysis. We should recognize the study has limitations and think about the results.

Kuo and Goodwin looked at data during a period of time early in the hospitalist movement; the results could be different if the study were to be repeated today. But we don’t know what the data would be today. I suppose the data could be better, worse, or about the same. The fact of the matter is that HM leaders—and most of the rest of us—knew that transitions of care, under the hospitalist model, were a potential weakness. How many times have you heard Win Whitcomb, MD, MHM, and John Nelson, MD, MHM, talk about the potential “voltage drop” with handoffs?

The good news is that leaders in our field have done something about this. Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is a program SHM has helped implement at dozens of hospitals across the country to address the issue of unnecessary hospital readmissions (www.hospitalmedicine. org/boost). Improving transitions of care and preventing unnecessary readmissions should be on the minds of all hospitalists. If your program and your hospital have not yet taken steps to address this issue, please let this be your wake-up call.

Show Me the Money

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality. I agree with you that it is hard to look at costs without looking at quality. Therein lies the basis for our nation’s move toward value-based purchasing of healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

When I hear hospitalists explain why the role of hospitalists was developed, the explanation often involves some discussion of cost and LOS reduction. Don’t get me wrong; it’s not that I believe HM has focused too much attention on cost reduction. I believe we have not focused enough on improving quality. This should not be surprising. Moving the bar on cost reduction is a lot easier than moving the bar on quality and patient safety. The first step toward improvement is an understanding of what you are doing currently. If your hospitalist group has not implemented a program to help its hospitalists measure the quality of care being provided, again, this is your wake-up call.

Last, but not least, for those of you who are not “surprised” by the results because of the belief that hospitalists were created to help the hospital save money and nothing more, I could not disagree with you more. I look at the roles that hospitalists have taken on in our nation’s hospitals, and I am incredibly proud to call myself a hospitalist.

Hospitalists are providing timely care when patients need it. Hospitalists are caring for patients without PCPs. Not only do hospitalists allow PCPs to provide more care in their outpatient clinics, but hospitalists also are caring for patients in ICUs in many places where there are not enough doctors sufficiently trained in critical care.

Rather than acting as an indictment on HM, I believe the Annals article makes a comment on the misalignment of incentives in our healthcare system.

It is 2011, not 1996; HM is here to stay. Most acute-care hospitals in America could not function without hospitalists. I applaud Kuo and Goodwin for doing the research and publishing their results. Let this be an opportunity for hospitalists around the country to think about how to implement systems to improve transitions of care and the quality of care we provide.

Dr. Li is president of SHM.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Int Med. 2011: 155:152-159.

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality.

I suspect most of you have reviewed the study or at least heard about it. Bob Wachter, MD, MHM, blogged about the study. An article about the study appeared in American Medical Association News. Even National Public Radio ran a piece about the study on their show “Morning Edition.”

I am, of course, referring to the study by Kuo and Goodwin, which was published in the Annals of Internal Medicine in early August.¹

In this study, the authors looked at a sample of patients (5%) with primary-care physicians (PCPs) enrolled in Medicare who were cared for by their PCP or a hospitalist during a period from 2001 to 2006. The authors stated their underlying hypotheses as:

• Hospitalist care would be associated with costs shifting from the hospital to the post-hospital setting;
• Hospitalist care would be associated with a decrease in discharges directly to home; and
• Discontinuities of care associated with hospitalist care would lead to a greater rate of visits to the emergency room and readmissions to the hospital, resulting in increased Medicare costs.

Did the authors say hospitalist care cost more? They can’t possibly be correct, can they? Don’t all the hospitalist studies show that hospitalists provide the same quality of care as primary-care doctors, except the costs are lower and the hospital length of stay (LOS) is shorter when hospitalists care for patients?

The point here is that these investigators look at the care not only during a patient’s hospital stay, but also for 30 days after discharge. This is something that had not been done previously—at least not on this scale.

Focus on Facts

And what did the authors find? Patients cared for by hospitalists, as compared to their PCPs, had a shorter LOS and lower in-hospital costs, but these patients also were less likely to be discharged directly to home, less likely to see their PCPs post-discharge, and had more hospital readmissions, ED visits, and nursing home visits after discharge.

Since its release two months ago, I have heard a lot of discussion about the study. Here are a few of the comments I’ve heard:

• “This was an observational study. You can’t possibly remove all confounders in an observational study.”
• “The authors looked at a time period early in the hospitalist movement. If they did the study today, the results would be different.”
• “The additional costs hospitalists incurred were only $50 per patient. Wouldn’t you pay $50 more if the care was better?”
• “This is why hospitals hired hospitalists. They save money for the hospitals. What did they expect to find?”

I agree that observational studies have limitations (even the authors acknowledged this), but this doesn’t mean results from observational studies are invalid. Some of us don’t want to hear this, but this actually was a pretty well-done study with a robust statistical analysis. We should recognize the study has limitations and think about the results.

Kuo and Goodwin looked at data during a period of time early in the hospitalist movement; the results could be different if the study were to be repeated today. But we don’t know what the data would be today. I suppose the data could be better, worse, or about the same. The fact of the matter is that HM leaders—and most of the rest of us—knew that transitions of care, under the hospitalist model, were a potential weakness. How many times have you heard Win Whitcomb, MD, MHM, and John Nelson, MD, MHM, talk about the potential “voltage drop” with handoffs?

The good news is that leaders in our field have done something about this. Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is a program SHM has helped implement at dozens of hospitals across the country to address the issue of unnecessary hospital readmissions (www.hospitalmedicine. org/boost). Improving transitions of care and preventing unnecessary readmissions should be on the minds of all hospitalists. If your program and your hospital have not yet taken steps to address this issue, please let this be your wake-up call.

Show Me the Money

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality. I agree with you that it is hard to look at costs without looking at quality. Therein lies the basis for our nation’s move toward value-based purchasing of healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

When I hear hospitalists explain why the role of hospitalists was developed, the explanation often involves some discussion of cost and LOS reduction. Don’t get me wrong; it’s not that I believe HM has focused too much attention on cost reduction. I believe we have not focused enough on improving quality. This should not be surprising. Moving the bar on cost reduction is a lot easier than moving the bar on quality and patient safety. The first step toward improvement is an understanding of what you are doing currently. If your hospitalist group has not implemented a program to help its hospitalists measure the quality of care being provided, again, this is your wake-up call.

Last, but not least, for those of you who are not “surprised” by the results because of the belief that hospitalists were created to help the hospital save money and nothing more, I could not disagree with you more. I look at the roles that hospitalists have taken on in our nation’s hospitals, and I am incredibly proud to call myself a hospitalist.

Hospitalists are providing timely care when patients need it. Hospitalists are caring for patients without PCPs. Not only do hospitalists allow PCPs to provide more care in their outpatient clinics, but hospitalists also are caring for patients in ICUs in many places where there are not enough doctors sufficiently trained in critical care.

Rather than acting as an indictment on HM, I believe the Annals article makes a comment on the misalignment of incentives in our healthcare system.

It is 2011, not 1996; HM is here to stay. Most acute-care hospitals in America could not function without hospitalists. I applaud Kuo and Goodwin for doing the research and publishing their results. Let this be an opportunity for hospitalists around the country to think about how to implement systems to improve transitions of care and the quality of care we provide.

Dr. Li is president of SHM.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Int Med. 2011: 155:152-159.

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality.

I suspect most of you have reviewed the study or at least heard about it. Bob Wachter, MD, MHM, blogged about the study. An article about the study appeared in American Medical Association News. Even National Public Radio ran a piece about the study on their show “Morning Edition.”

I am, of course, referring to the study by Kuo and Goodwin, which was published in the Annals of Internal Medicine in early August.¹

In this study, the authors looked at a sample of patients (5%) with primary-care physicians (PCPs) enrolled in Medicare who were cared for by their PCP or a hospitalist during a period from 2001 to 2006. The authors stated their underlying hypotheses as:

• Hospitalist care would be associated with costs shifting from the hospital to the post-hospital setting;
• Hospitalist care would be associated with a decrease in discharges directly to home; and
• Discontinuities of care associated with hospitalist care would lead to a greater rate of visits to the emergency room and readmissions to the hospital, resulting in increased Medicare costs.

Did the authors say hospitalist care cost more? They can’t possibly be correct, can they? Don’t all the hospitalist studies show that hospitalists provide the same quality of care as primary-care doctors, except the costs are lower and the hospital length of stay (LOS) is shorter when hospitalists care for patients?

The point here is that these investigators look at the care not only during a patient’s hospital stay, but also for 30 days after discharge. This is something that had not been done previously—at least not on this scale.

Focus on Facts

And what did the authors find? Patients cared for by hospitalists, as compared to their PCPs, had a shorter LOS and lower in-hospital costs, but these patients also were less likely to be discharged directly to home, less likely to see their PCPs post-discharge, and had more hospital readmissions, ED visits, and nursing home visits after discharge.

Since its release two months ago, I have heard a lot of discussion about the study. Here are a few of the comments I’ve heard:

• “This was an observational study. You can’t possibly remove all confounders in an observational study.”
• “The authors looked at a time period early in the hospitalist movement. If they did the study today, the results would be different.”
• “The additional costs hospitalists incurred were only $50 per patient. Wouldn’t you pay $50 more if the care was better?”
• “This is why hospitals hired hospitalists. They save money for the hospitals. What did they expect to find?”

I agree that observational studies have limitations (even the authors acknowledged this), but this doesn’t mean results from observational studies are invalid. Some of us don’t want to hear this, but this actually was a pretty well-done study with a robust statistical analysis. We should recognize the study has limitations and think about the results.

Kuo and Goodwin looked at data during a period of time early in the hospitalist movement; the results could be different if the study were to be repeated today. But we don’t know what the data would be today. I suppose the data could be better, worse, or about the same. The fact of the matter is that HM leaders—and most of the rest of us—knew that transitions of care, under the hospitalist model, were a potential weakness. How many times have you heard Win Whitcomb, MD, MHM, and John Nelson, MD, MHM, talk about the potential “voltage drop” with handoffs?

The good news is that leaders in our field have done something about this. Project BOOST (Better Outcomes for Older Adults through Safer Transitions) is a program SHM has helped implement at dozens of hospitals across the country to address the issue of unnecessary hospital readmissions (www.hospitalmedicine. org/boost). Improving transitions of care and preventing unnecessary readmissions should be on the minds of all hospitalists. If your program and your hospital have not yet taken steps to address this issue, please let this be your wake-up call.

Show Me the Money

For those who say they would pay $50 more per patient if the quality is better, here’s the problem: Show me the data that say hospitalist care is higher-quality. I agree with you that it is hard to look at costs without looking at quality. Therein lies the basis for our nation’s move toward value-based purchasing of healthcare (see “Value-Based Purchasing Raises the Stakes,” May 2011).

When I hear hospitalists explain why the role of hospitalists was developed, the explanation often involves some discussion of cost and LOS reduction. Don’t get me wrong; it’s not that I believe HM has focused too much attention on cost reduction. I believe we have not focused enough on improving quality. This should not be surprising. Moving the bar on cost reduction is a lot easier than moving the bar on quality and patient safety. The first step toward improvement is an understanding of what you are doing currently. If your hospitalist group has not implemented a program to help its hospitalists measure the quality of care being provided, again, this is your wake-up call.

Last, but not least, for those of you who are not “surprised” by the results because of the belief that hospitalists were created to help the hospital save money and nothing more, I could not disagree with you more. I look at the roles that hospitalists have taken on in our nation’s hospitals, and I am incredibly proud to call myself a hospitalist.

Hospitalists are providing timely care when patients need it. Hospitalists are caring for patients without PCPs. Not only do hospitalists allow PCPs to provide more care in their outpatient clinics, but hospitalists also are caring for patients in ICUs in many places where there are not enough doctors sufficiently trained in critical care.

Rather than acting as an indictment on HM, I believe the Annals article makes a comment on the misalignment of incentives in our healthcare system.

It is 2011, not 1996; HM is here to stay. Most acute-care hospitals in America could not function without hospitalists. I applaud Kuo and Goodwin for doing the research and publishing their results. Let this be an opportunity for hospitalists around the country to think about how to implement systems to improve transitions of care and the quality of care we provide.

Dr. Li is president of SHM.

Reference

1. Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Int Med. 2011: 155:152-159.

Last month (see “Hospital-Focused Practice,” Septem-ber 2011, p. 61), I discussed the adoption of the hospitalist model of practice by many specialties, some of the common issues they face, and highlighted a national meeting to examine this phenomenon (for more information on the meeting, visit www.hospitalmedicine/hfpm). This month, relying mostly on my own experience with this practice model, I’ll drill deeper into OB hospitalists (also known as laborists). While there are a lot of ways in which hospitalist practice in many specialties are the same, laborists differ from those in other fields in important and interesting ways.

Prevalence

One of the most informative sources about the “laborist movement” is ObGynHospitalist.com, a website started and managed by Dr. Rob Olson, an enterprising laborist in Bellingham, Wash. As of July, the site listed 132 laborist programs nationwide (and that figure likely underestimates the actual number in operation). A survey of registered users of the website in April yielded 106 responses, representing a 24% response rate. Seventy-five of the respondents indicated they were full-time laborists.

Unique Drivers

Because obstetric malpractice costs are so high, and many lawsuits are related to delayed response to obstetric emergencies, there is hope (not much hard proof yet) that outcomes will be better, and lawsuits less common or less costly.¹ So the hope of reduced malpractice costs figures more prominently into the cost-benefit analysis of the OB hospitalist model than most other types of HM practice.

Financial Model

It appears that all hospitalist models require financial support over and above professional fee revenue. Hospitals usually are willing (happy?) to provide this money because they can make back even more as a result of increased patient volume/market share or lower costs. And, as is the case for hospitalists in other specialties, laborist presence can be an asset in recruitment and retention of other OBGYNs.

I think the most interesting feature of laborist practice is that in many settings, it has the potential to open new sources of revenue—both hospital “facility fee” and professional fee revenue. A common practice in many hospitals is for obstetricians to send patients, or for them to self-present, to labor and delivery to be checked for a cold, vomiting, or whether labor has started. Many times, a nurse performs these checks, communicates with a doctor, then discharges the patient—and no bill is generated. An on-site laborist can see the same patients (presumably making for a higher-quality visit for the patient) and, assuming the visit is medically necessary, both a facility and professional charge can be submitted. Revenue from such visits can go a long way toward making up the difference between the total cost of the laborist program and fee collections. This adds to patient safety, as each patient is evaluated in person by a physician rather than only a nurse.

In most settings, the laborist submits a charge for delivery only for unassigned patients. For those patients who “belong to” another OB who provided prenatal care, it is often most practical for that doctor to submit the global fee for prenatal care and delivery, and to pay the laborist program an agreed-upon rate for each service provided.

Compensation

Laborists often are paid an hourly rate, and they typically don’t have a salary component tied to work relative-value unit (wRVU) production or other productivity metrics. Total annual compensation is typically lower than private-practice OBGYN physicians. It also varies widely, depending on local market forces, job description, and workload. Most programs are trying to implement meaningful quality bonuses for laborists.

Scope of Practice

Laborists typically provide care to all unassigned patients who present to labor and delivery, and perform deliveries, C-sections, and other services on patients when requested by OBs in traditional practice. Requests arise when an OB simply needs to be relieved of being on call for their private patients, or when an emergency arises. (These “as-needed” referrals are different from the most common arrangement for “medical hospitalist” practices that ask other doctors to refer all or none of their patients, not just when they are otherwise occupied.)

Lastly, the laborist might serve as surgical assistant to other OBGYNs. In nearly all settings, there is no need to require that any physicians refer to the laborist, and the other OBs are free to decide when to refer.

A reasonably common scenario is that, to avoid disruption of scheduled office hours, an OB in traditional practice might ask that the laborist manage a patient who presents in labor. But if still undelivered at the close of office hours, the traditional OB might assume care from that point on or have the laborist remain responsible through delivery. The traditional OB usually will make post-partum “rounding” visits on all of their patients but could rely on the laborist for these visits.

In most cases, the laborist does not have any scheduled gynecologic procedures, though he or she may see GYN consults throughout the hospital as time permits. Laborists typically have no outpatient responsibilities, but some OBGYN hospitalists cover GYN in the ED.

Operational Structure

Although models vary significantly, the single most common arrangement is for laborists to work 24-hour, in-house shifts. Rarely is there a need or justification to have more than one laborist on at a time. For a single physician, seven or eight 24-hour shifts per month is considered full-time. My experience is that most laborists are employed by the hospital in which they work.

As is the case in every specialty, some large OBGYN groups adopt a rotating laborist model, in which one member of their group becomes the laborist for 24 hours at a time, during which they are relieved of all other responsibilities.

Recruitment

ObGynHospitalist.com shows that, as of July, 40 of the 132 laborist programs that had identified themselves on the site were recruiting. My experience is that unlike “medical hospitalist” practices, which tend to successfully recruit those very early in their career, or “surgical hospitalist” programs, which target mid- to late-career general surgeons, laborist candidates come from any point in their careers. Most programs prefer that a laborist has several years of post-residency experience, but they generally have no other preference.

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Reference

1. Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol. 2008;112(6):1279-1283.

Last month (see “Hospital-Focused Practice,” Septem-ber 2011, p. 61), I discussed the adoption of the hospitalist model of practice by many specialties, some of the common issues they face, and highlighted a national meeting to examine this phenomenon (for more information on the meeting, visit www.hospitalmedicine/hfpm). This month, relying mostly on my own experience with this practice model, I’ll drill deeper into OB hospitalists (also known as laborists). While there are a lot of ways in which hospitalist practice in many specialties are the same, laborists differ from those in other fields in important and interesting ways.

Prevalence

One of the most informative sources about the “laborist movement” is ObGynHospitalist.com, a website started and managed by Dr. Rob Olson, an enterprising laborist in Bellingham, Wash. As of July, the site listed 132 laborist programs nationwide (and that figure likely underestimates the actual number in operation). A survey of registered users of the website in April yielded 106 responses, representing a 24% response rate. Seventy-five of the respondents indicated they were full-time laborists.

Unique Drivers

Because obstetric malpractice costs are so high, and many lawsuits are related to delayed response to obstetric emergencies, there is hope (not much hard proof yet) that outcomes will be better, and lawsuits less common or less costly.¹ So the hope of reduced malpractice costs figures more prominently into the cost-benefit analysis of the OB hospitalist model than most other types of HM practice.

Financial Model

It appears that all hospitalist models require financial support over and above professional fee revenue. Hospitals usually are willing (happy?) to provide this money because they can make back even more as a result of increased patient volume/market share or lower costs. And, as is the case for hospitalists in other specialties, laborist presence can be an asset in recruitment and retention of other OBGYNs.

I think the most interesting feature of laborist practice is that in many settings, it has the potential to open new sources of revenue—both hospital “facility fee” and professional fee revenue. A common practice in many hospitals is for obstetricians to send patients, or for them to self-present, to labor and delivery to be checked for a cold, vomiting, or whether labor has started. Many times, a nurse performs these checks, communicates with a doctor, then discharges the patient—and no bill is generated. An on-site laborist can see the same patients (presumably making for a higher-quality visit for the patient) and, assuming the visit is medically necessary, both a facility and professional charge can be submitted. Revenue from such visits can go a long way toward making up the difference between the total cost of the laborist program and fee collections. This adds to patient safety, as each patient is evaluated in person by a physician rather than only a nurse.

In most settings, the laborist submits a charge for delivery only for unassigned patients. For those patients who “belong to” another OB who provided prenatal care, it is often most practical for that doctor to submit the global fee for prenatal care and delivery, and to pay the laborist program an agreed-upon rate for each service provided.

Compensation

Laborists often are paid an hourly rate, and they typically don’t have a salary component tied to work relative-value unit (wRVU) production or other productivity metrics. Total annual compensation is typically lower than private-practice OBGYN physicians. It also varies widely, depending on local market forces, job description, and workload. Most programs are trying to implement meaningful quality bonuses for laborists.

Scope of Practice

Laborists typically provide care to all unassigned patients who present to labor and delivery, and perform deliveries, C-sections, and other services on patients when requested by OBs in traditional practice. Requests arise when an OB simply needs to be relieved of being on call for their private patients, or when an emergency arises. (These “as-needed” referrals are different from the most common arrangement for “medical hospitalist” practices that ask other doctors to refer all or none of their patients, not just when they are otherwise occupied.)

Lastly, the laborist might serve as surgical assistant to other OBGYNs. In nearly all settings, there is no need to require that any physicians refer to the laborist, and the other OBs are free to decide when to refer.

A reasonably common scenario is that, to avoid disruption of scheduled office hours, an OB in traditional practice might ask that the laborist manage a patient who presents in labor. But if still undelivered at the close of office hours, the traditional OB might assume care from that point on or have the laborist remain responsible through delivery. The traditional OB usually will make post-partum “rounding” visits on all of their patients but could rely on the laborist for these visits.

In most cases, the laborist does not have any scheduled gynecologic procedures, though he or she may see GYN consults throughout the hospital as time permits. Laborists typically have no outpatient responsibilities, but some OBGYN hospitalists cover GYN in the ED.

Operational Structure

Although models vary significantly, the single most common arrangement is for laborists to work 24-hour, in-house shifts. Rarely is there a need or justification to have more than one laborist on at a time. For a single physician, seven or eight 24-hour shifts per month is considered full-time. My experience is that most laborists are employed by the hospital in which they work.

As is the case in every specialty, some large OBGYN groups adopt a rotating laborist model, in which one member of their group becomes the laborist for 24 hours at a time, during which they are relieved of all other responsibilities.

Recruitment

ObGynHospitalist.com shows that, as of July, 40 of the 132 laborist programs that had identified themselves on the site were recruiting. My experience is that unlike “medical hospitalist” practices, which tend to successfully recruit those very early in their career, or “surgical hospitalist” programs, which target mid- to late-career general surgeons, laborist candidates come from any point in their careers. Most programs prefer that a laborist has several years of post-residency experience, but they generally have no other preference.

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Reference

1. Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol. 2008;112(6):1279-1283.

Last month (see “Hospital-Focused Practice,” Septem-ber 2011, p. 61), I discussed the adoption of the hospitalist model of practice by many specialties, some of the common issues they face, and highlighted a national meeting to examine this phenomenon (for more information on the meeting, visit www.hospitalmedicine/hfpm). This month, relying mostly on my own experience with this practice model, I’ll drill deeper into OB hospitalists (also known as laborists). While there are a lot of ways in which hospitalist practice in many specialties are the same, laborists differ from those in other fields in important and interesting ways.

Prevalence

One of the most informative sources about the “laborist movement” is ObGynHospitalist.com, a website started and managed by Dr. Rob Olson, an enterprising laborist in Bellingham, Wash. As of July, the site listed 132 laborist programs nationwide (and that figure likely underestimates the actual number in operation). A survey of registered users of the website in April yielded 106 responses, representing a 24% response rate. Seventy-five of the respondents indicated they were full-time laborists.

Unique Drivers

Because obstetric malpractice costs are so high, and many lawsuits are related to delayed response to obstetric emergencies, there is hope (not much hard proof yet) that outcomes will be better, and lawsuits less common or less costly.¹ So the hope of reduced malpractice costs figures more prominently into the cost-benefit analysis of the OB hospitalist model than most other types of HM practice.

Financial Model

It appears that all hospitalist models require financial support over and above professional fee revenue. Hospitals usually are willing (happy?) to provide this money because they can make back even more as a result of increased patient volume/market share or lower costs. And, as is the case for hospitalists in other specialties, laborist presence can be an asset in recruitment and retention of other OBGYNs.

I think the most interesting feature of laborist practice is that in many settings, it has the potential to open new sources of revenue—both hospital “facility fee” and professional fee revenue. A common practice in many hospitals is for obstetricians to send patients, or for them to self-present, to labor and delivery to be checked for a cold, vomiting, or whether labor has started. Many times, a nurse performs these checks, communicates with a doctor, then discharges the patient—and no bill is generated. An on-site laborist can see the same patients (presumably making for a higher-quality visit for the patient) and, assuming the visit is medically necessary, both a facility and professional charge can be submitted. Revenue from such visits can go a long way toward making up the difference between the total cost of the laborist program and fee collections. This adds to patient safety, as each patient is evaluated in person by a physician rather than only a nurse.

In most settings, the laborist submits a charge for delivery only for unassigned patients. For those patients who “belong to” another OB who provided prenatal care, it is often most practical for that doctor to submit the global fee for prenatal care and delivery, and to pay the laborist program an agreed-upon rate for each service provided.

Compensation

Laborists often are paid an hourly rate, and they typically don’t have a salary component tied to work relative-value unit (wRVU) production or other productivity metrics. Total annual compensation is typically lower than private-practice OBGYN physicians. It also varies widely, depending on local market forces, job description, and workload. Most programs are trying to implement meaningful quality bonuses for laborists.

Scope of Practice

Laborists typically provide care to all unassigned patients who present to labor and delivery, and perform deliveries, C-sections, and other services on patients when requested by OBs in traditional practice. Requests arise when an OB simply needs to be relieved of being on call for their private patients, or when an emergency arises. (These “as-needed” referrals are different from the most common arrangement for “medical hospitalist” practices that ask other doctors to refer all or none of their patients, not just when they are otherwise occupied.)

Lastly, the laborist might serve as surgical assistant to other OBGYNs. In nearly all settings, there is no need to require that any physicians refer to the laborist, and the other OBs are free to decide when to refer.

A reasonably common scenario is that, to avoid disruption of scheduled office hours, an OB in traditional practice might ask that the laborist manage a patient who presents in labor. But if still undelivered at the close of office hours, the traditional OB might assume care from that point on or have the laborist remain responsible through delivery. The traditional OB usually will make post-partum “rounding” visits on all of their patients but could rely on the laborist for these visits.

In most cases, the laborist does not have any scheduled gynecologic procedures, though he or she may see GYN consults throughout the hospital as time permits. Laborists typically have no outpatient responsibilities, but some OBGYN hospitalists cover GYN in the ED.

Operational Structure

Although models vary significantly, the single most common arrangement is for laborists to work 24-hour, in-house shifts. Rarely is there a need or justification to have more than one laborist on at a time. For a single physician, seven or eight 24-hour shifts per month is considered full-time. My experience is that most laborists are employed by the hospital in which they work.

As is the case in every specialty, some large OBGYN groups adopt a rotating laborist model, in which one member of their group becomes the laborist for 24 hours at a time, during which they are relieved of all other responsibilities.

Recruitment

ObGynHospitalist.com shows that, as of July, 40 of the 132 laborist programs that had identified themselves on the site were recruiting. My experience is that unlike “medical hospitalist” practices, which tend to successfully recruit those very early in their career, or “surgical hospitalist” programs, which target mid- to late-career general surgeons, laborist candidates come from any point in their careers. Most programs prefer that a laborist has several years of post-residency experience, but they generally have no other preference.

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Reference

1. Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol. 2008;112(6):1279-1283.

Click here to listen to Alan Pisarski.

Click here to listen to Mark Hamm.

Click here to listen to Alan Pisarski.

Click here to listen to Mark Hamm.

Click here to listen to Alan Pisarski.

Click here to listen to Mark Hamm.

Establishing mutual respect and trust between hospitalists and nurses is an important part of ensuring patient safety, whether you’re on your first job or your 20th, says Angela Beck, RN, director of critical-care services at Nebraska Medical Center in Omaha.

“Nurses are important coordinators of care,” she says. “Recognizing and valuing nurses for that is truly the most important thing for the patient, and can also help hospitalists build relationships.”

Key Partners

Forming a collaborative relationship with the nursing service might depend on where you start. At Northwestern Memorial Hospital in Chicago, the nursing service enjoys a “close and collaborative relationship” with hospitalists, according to Kristin Ramsey, RN, MSN, MPPM, NE-BC, associate chief nurse and executive director of operations. New hospitalists are oriented to the care-delivery models on the inpatient care units. In addition, hospitalists are acculturated into the hospital’s coleadership model.

“We have partnered with our hospitalists to create a model in which the physician and nurse leader collaboratively lead the development of multidisciplinary, subspecialty teams to ensure quality outcomes,” Ramsey says. “The model is so successful with the hospitalists that we are now extending it to other areas in the organization.”

Round Sharing

Absent a formalized training protocol for partnering with nursing, hospitalists still can learn a great deal by listening to and communicating with the nursing staff, says Connie Ogden, RN, MSN, NEA-BC, executive director of adult acute services at Nebraska Medical Center. “Nurses are there around the clock caring for patients and may have a different insight” about patients’ evolving conditions, she says.

Care for the patient improves if everyone is on the same page, Ogden adds. That’s why it makes sense, she says, to include nurses during rounds. Beck agrees: “If nurses aren’t there to hear how the plan of care comes about, there is no reason to believe they can effectively describe it once the physician turns around and walks away to see another patient.”

In critical-care units, according to Beck, nurses can function as a bridge between patients and physicians. For example, they can help patients define and express their goals. Some of these goals can be incremental, she notes, such as “I really want to get out of bed this afternoon,” or “I really want my family here to listen to this message.”

Different Role, Same Goal

As director of adult acute services, Ogden often receives complaints from physicians about calls they receive from nurses. Often, these calls emanate from a concern for the patient (e.g. a 2 a.m. call for a Tylenol order to address a headache) or from the requirement that nurses follow policy and clarify orders. If hospitalists understand the back story of the call, their perception of its purpose can change.

Although there have been strides toward better nurse-physician collaboration, “we still have a lot of opportunities for improvement,” Beck asserts.

Establishing mutual respect and trust is not an overnight accomplishment. As Ogden explains, physicians and nurses have different roles, but they share the same goal: quality outcomes in patient care.

Gretchen Henkel is a freelance writer based in southern California.

► For more career-related articles, visit the SHM Career Center.

Establishing mutual respect and trust between hospitalists and nurses is an important part of ensuring patient safety, whether you’re on your first job or your 20th, says Angela Beck, RN, director of critical-care services at Nebraska Medical Center in Omaha.

“Nurses are important coordinators of care,” she says. “Recognizing and valuing nurses for that is truly the most important thing for the patient, and can also help hospitalists build relationships.”

Key Partners

Forming a collaborative relationship with the nursing service might depend on where you start. At Northwestern Memorial Hospital in Chicago, the nursing service enjoys a “close and collaborative relationship” with hospitalists, according to Kristin Ramsey, RN, MSN, MPPM, NE-BC, associate chief nurse and executive director of operations. New hospitalists are oriented to the care-delivery models on the inpatient care units. In addition, hospitalists are acculturated into the hospital’s coleadership model.

“We have partnered with our hospitalists to create a model in which the physician and nurse leader collaboratively lead the development of multidisciplinary, subspecialty teams to ensure quality outcomes,” Ramsey says. “The model is so successful with the hospitalists that we are now extending it to other areas in the organization.”

Round Sharing

Absent a formalized training protocol for partnering with nursing, hospitalists still can learn a great deal by listening to and communicating with the nursing staff, says Connie Ogden, RN, MSN, NEA-BC, executive director of adult acute services at Nebraska Medical Center. “Nurses are there around the clock caring for patients and may have a different insight” about patients’ evolving conditions, she says.

Care for the patient improves if everyone is on the same page, Ogden adds. That’s why it makes sense, she says, to include nurses during rounds. Beck agrees: “If nurses aren’t there to hear how the plan of care comes about, there is no reason to believe they can effectively describe it once the physician turns around and walks away to see another patient.”

In critical-care units, according to Beck, nurses can function as a bridge between patients and physicians. For example, they can help patients define and express their goals. Some of these goals can be incremental, she notes, such as “I really want to get out of bed this afternoon,” or “I really want my family here to listen to this message.”

Different Role, Same Goal

As director of adult acute services, Ogden often receives complaints from physicians about calls they receive from nurses. Often, these calls emanate from a concern for the patient (e.g. a 2 a.m. call for a Tylenol order to address a headache) or from the requirement that nurses follow policy and clarify orders. If hospitalists understand the back story of the call, their perception of its purpose can change.

Although there have been strides toward better nurse-physician collaboration, “we still have a lot of opportunities for improvement,” Beck asserts.

Establishing mutual respect and trust is not an overnight accomplishment. As Ogden explains, physicians and nurses have different roles, but they share the same goal: quality outcomes in patient care.

Gretchen Henkel is a freelance writer based in southern California.

► For more career-related articles, visit the SHM Career Center.

Establishing mutual respect and trust between hospitalists and nurses is an important part of ensuring patient safety, whether you’re on your first job or your 20th, says Angela Beck, RN, director of critical-care services at Nebraska Medical Center in Omaha.

“Nurses are important coordinators of care,” she says. “Recognizing and valuing nurses for that is truly the most important thing for the patient, and can also help hospitalists build relationships.”

Key Partners

Forming a collaborative relationship with the nursing service might depend on where you start. At Northwestern Memorial Hospital in Chicago, the nursing service enjoys a “close and collaborative relationship” with hospitalists, according to Kristin Ramsey, RN, MSN, MPPM, NE-BC, associate chief nurse and executive director of operations. New hospitalists are oriented to the care-delivery models on the inpatient care units. In addition, hospitalists are acculturated into the hospital’s coleadership model.

“We have partnered with our hospitalists to create a model in which the physician and nurse leader collaboratively lead the development of multidisciplinary, subspecialty teams to ensure quality outcomes,” Ramsey says. “The model is so successful with the hospitalists that we are now extending it to other areas in the organization.”

Round Sharing

Absent a formalized training protocol for partnering with nursing, hospitalists still can learn a great deal by listening to and communicating with the nursing staff, says Connie Ogden, RN, MSN, NEA-BC, executive director of adult acute services at Nebraska Medical Center. “Nurses are there around the clock caring for patients and may have a different insight” about patients’ evolving conditions, she says.

Care for the patient improves if everyone is on the same page, Ogden adds. That’s why it makes sense, she says, to include nurses during rounds. Beck agrees: “If nurses aren’t there to hear how the plan of care comes about, there is no reason to believe they can effectively describe it once the physician turns around and walks away to see another patient.”

In critical-care units, according to Beck, nurses can function as a bridge between patients and physicians. For example, they can help patients define and express their goals. Some of these goals can be incremental, she notes, such as “I really want to get out of bed this afternoon,” or “I really want my family here to listen to this message.”

Different Role, Same Goal

As director of adult acute services, Ogden often receives complaints from physicians about calls they receive from nurses. Often, these calls emanate from a concern for the patient (e.g. a 2 a.m. call for a Tylenol order to address a headache) or from the requirement that nurses follow policy and clarify orders. If hospitalists understand the back story of the call, their perception of its purpose can change.

Although there have been strides toward better nurse-physician collaboration, “we still have a lot of opportunities for improvement,” Beck asserts.

Establishing mutual respect and trust is not an overnight accomplishment. As Ogden explains, physicians and nurses have different roles, but they share the same goal: quality outcomes in patient care.

Gretchen Henkel is a freelance writer based in southern California.

► For more career-related articles, visit the SHM Career Center.

Welcome to “Survey Insights,” a new section devoted to exploring and interpreting information from the survey conducted jointly by SHM and the Medical Group Management Association (MGMA). Each month we will focus on a specific topic, providing not only the survey results, but also background information and commentary from members of SHM’s Practice Analysis Committee.

With this month’s release of the 2010-2011 State of Hospital Medicine report, we now have several useful data points regarding the work of nocturnists in HM. In the survey, nocturnist was defined as an individual hospitalist who predominantly works a schedule providing in-house night coverage for inpatients. The question “Does your practice include nocturnists?” was part of the survey’s HM Supplement, and was answered by 238 of the 307 supplement respondents. As was the case last year, 41% of HM practices responding to the survey reported having nocturnists working in their group.

Although less than half of respondent groups reported having nocturnists, more than 55% of the individual hospitalists in the data set worked in groups with nocturnists. This suggests that nocturnists tend to be found more often in larger HM groups.

click for large version

The proportion of night coverage provided by nocturnists varied widely among groups, as can be seen in the chart (see “Percentage of Night Coverage by Nocturnists,” p. 11). Only 16% of the groups with nocturnists used them for all of their night coverage. For about half the groups, the nocturnists provide from one-quarter to three-quarters of the night coverage. This year, data were also obtained on compensation and productivity for 131 nocturnists. Perhaps the most surprising finding is that the median compensation reported for nocturnists in practices that care for adults was $215,000, about 2.5% lower than the median compensation reported for all adult hospitalists. (There was not enough pediatric nocturnist data to report results.)

It’s no surprise, however, that median annual nocturnist productivity was 3,058 wRVUs, about 27% lower than the productivity reported for all adult hospitalists. This suggests that even though median compensation for nocturnists is a bit lower, the “juice to squeeze” ratio for working exclusively at night remains higher than for daytime work.

According to committee member Dan Fuller, president and cofounder of Alpharetta, Ga.-based InCompass Health Inc., “this data supports what we already know: that nocturnists are not as productive as the typical rounding hospitalist. However, they are necessary in most of the larger models, given the need for a physician to be in-house at night for both admissions and emergencies.”

Committee members weren’t sure how to interpret the lower nocturnist compensation, because for many the finding differs from the situation in their own practices. Chris Frost, MD, FHM, vice president of operations for Knoxville, Tenn.-based TeamHealth, postulates that “unless productivity thresholds are adjusted for nocturnists, they will rarely achieve productivity incentives” earned by daytime hospitalists. And PAC member John Nelson, MD, MHM, points out, “There’s more than one way of compensating nocturnists for the inconvenience of working at night. The three nocturnists in our practice, for example, make about the same as everyone else but only work 10 nights a month.”

Leslie Flores, SHM senior advisor, practice management

Welcome to “Survey Insights,” a new section devoted to exploring and interpreting information from the survey conducted jointly by SHM and the Medical Group Management Association (MGMA). Each month we will focus on a specific topic, providing not only the survey results, but also background information and commentary from members of SHM’s Practice Analysis Committee.

With this month’s release of the 2010-2011 State of Hospital Medicine report, we now have several useful data points regarding the work of nocturnists in HM. In the survey, nocturnist was defined as an individual hospitalist who predominantly works a schedule providing in-house night coverage for inpatients. The question “Does your practice include nocturnists?” was part of the survey’s HM Supplement, and was answered by 238 of the 307 supplement respondents. As was the case last year, 41% of HM practices responding to the survey reported having nocturnists working in their group.

Although less than half of respondent groups reported having nocturnists, more than 55% of the individual hospitalists in the data set worked in groups with nocturnists. This suggests that nocturnists tend to be found more often in larger HM groups.

click for large version

The proportion of night coverage provided by nocturnists varied widely among groups, as can be seen in the chart (see “Percentage of Night Coverage by Nocturnists,” p. 11). Only 16% of the groups with nocturnists used them for all of their night coverage. For about half the groups, the nocturnists provide from one-quarter to three-quarters of the night coverage. This year, data were also obtained on compensation and productivity for 131 nocturnists. Perhaps the most surprising finding is that the median compensation reported for nocturnists in practices that care for adults was $215,000, about 2.5% lower than the median compensation reported for all adult hospitalists. (There was not enough pediatric nocturnist data to report results.)

It’s no surprise, however, that median annual nocturnist productivity was 3,058 wRVUs, about 27% lower than the productivity reported for all adult hospitalists. This suggests that even though median compensation for nocturnists is a bit lower, the “juice to squeeze” ratio for working exclusively at night remains higher than for daytime work.

According to committee member Dan Fuller, president and cofounder of Alpharetta, Ga.-based InCompass Health Inc., “this data supports what we already know: that nocturnists are not as productive as the typical rounding hospitalist. However, they are necessary in most of the larger models, given the need for a physician to be in-house at night for both admissions and emergencies.”

Committee members weren’t sure how to interpret the lower nocturnist compensation, because for many the finding differs from the situation in their own practices. Chris Frost, MD, FHM, vice president of operations for Knoxville, Tenn.-based TeamHealth, postulates that “unless productivity thresholds are adjusted for nocturnists, they will rarely achieve productivity incentives” earned by daytime hospitalists. And PAC member John Nelson, MD, MHM, points out, “There’s more than one way of compensating nocturnists for the inconvenience of working at night. The three nocturnists in our practice, for example, make about the same as everyone else but only work 10 nights a month.”

Leslie Flores, SHM senior advisor, practice management

Welcome to “Survey Insights,” a new section devoted to exploring and interpreting information from the survey conducted jointly by SHM and the Medical Group Management Association (MGMA). Each month we will focus on a specific topic, providing not only the survey results, but also background information and commentary from members of SHM’s Practice Analysis Committee.

With this month’s release of the 2010-2011 State of Hospital Medicine report, we now have several useful data points regarding the work of nocturnists in HM. In the survey, nocturnist was defined as an individual hospitalist who predominantly works a schedule providing in-house night coverage for inpatients. The question “Does your practice include nocturnists?” was part of the survey’s HM Supplement, and was answered by 238 of the 307 supplement respondents. As was the case last year, 41% of HM practices responding to the survey reported having nocturnists working in their group.

Although less than half of respondent groups reported having nocturnists, more than 55% of the individual hospitalists in the data set worked in groups with nocturnists. This suggests that nocturnists tend to be found more often in larger HM groups.

click for large version

The proportion of night coverage provided by nocturnists varied widely among groups, as can be seen in the chart (see “Percentage of Night Coverage by Nocturnists,” p. 11). Only 16% of the groups with nocturnists used them for all of their night coverage. For about half the groups, the nocturnists provide from one-quarter to three-quarters of the night coverage. This year, data were also obtained on compensation and productivity for 131 nocturnists. Perhaps the most surprising finding is that the median compensation reported for nocturnists in practices that care for adults was $215,000, about 2.5% lower than the median compensation reported for all adult hospitalists. (There was not enough pediatric nocturnist data to report results.)

It’s no surprise, however, that median annual nocturnist productivity was 3,058 wRVUs, about 27% lower than the productivity reported for all adult hospitalists. This suggests that even though median compensation for nocturnists is a bit lower, the “juice to squeeze” ratio for working exclusively at night remains higher than for daytime work.

According to committee member Dan Fuller, president and cofounder of Alpharetta, Ga.-based InCompass Health Inc., “this data supports what we already know: that nocturnists are not as productive as the typical rounding hospitalist. However, they are necessary in most of the larger models, given the need for a physician to be in-house at night for both admissions and emergencies.”

Committee members weren’t sure how to interpret the lower nocturnist compensation, because for many the finding differs from the situation in their own practices. Chris Frost, MD, FHM, vice president of operations for Knoxville, Tenn.-based TeamHealth, postulates that “unless productivity thresholds are adjusted for nocturnists, they will rarely achieve productivity incentives” earned by daytime hospitalists. And PAC member John Nelson, MD, MHM, points out, “There’s more than one way of compensating nocturnists for the inconvenience of working at night. The three nocturnists in our practice, for example, make about the same as everyone else but only work 10 nights a month.”

Leslie Flores, SHM senior advisor, practice management