Robert Coben, MD, academic coordinator for the Gastrointestinal Fellowship Program at Thomas Jefferson University Hospital in Philadelphia, says that when patients get admitted with chest pain for reasons other than a heart-related problem, he is frequently called on to do an endoscopy right away.

But that’s usually not the best starting point, he says.

“I would say the best test would be to just place the patient on a high-dose proton pump inhibitor once or twice a day first, to see if those symptoms resolve,” he says. “Many times we’re called in to do an upper endoscopy. … And many times that’s not really indicated unless they’re

having other alarm symptoms such as dysphagia, odynophagia, and weight loss.”

“Many times we’re called in to do an upper endoscopy … And many times that’s not really indicated unless they’re having other alarm symptoms such as dysphagia, odynophagia, and weight loss.” —Robert Coben, MD

Marcelo Vela, MD, gastroenterologist and hepatologist at the Mayo Clinic in Scottsdale, Ariz., and an associate editor with Clinical Gastroenterology and Hepatology, adds that it’s okay to start a patient with non-cardiac chest pain on PPIs when they have concomitant, typical symptoms of gastroesophageal reflux disease (GERD)—heartburn and acid regurgitation. But in patients without such symptoms, further testing is needed to confirm GERD, he says (Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308–328, Table 1).

This evaluation is usually done in the outpatient setting, he says.

Dr. Vela suggests more care might be needed in the prescribing of PPIs. He says he frequently sees patients who have been hospitalized and put on a PPI without a clear reason.

“They get admitted for various reasons—DVT [deep vein thrombosis], pneumonia, whatever, and then in the hospital, they get started on a proton pump inhibitor for unclear reasons. And then they leave and they stay on it,” Dr. Vela says.

When he asks why, patients just say, “On my last hospitalization, they put me on it,” he says.

“I think you should only leave the hospital on a PPI with a very clear indication—either you found an ulcer or the patient clearly has GERD” or some other reason, he says. “They’re fairly benign medications, but if there’s no indication for it, there’s no benefit.”

Robert Coben, MD, academic coordinator for the Gastrointestinal Fellowship Program at Thomas Jefferson University Hospital in Philadelphia, says that when patients get admitted with chest pain for reasons other than a heart-related problem, he is frequently called on to do an endoscopy right away.

But that’s usually not the best starting point, he says.

“I would say the best test would be to just place the patient on a high-dose proton pump inhibitor once or twice a day first, to see if those symptoms resolve,” he says. “Many times we’re called in to do an upper endoscopy. … And many times that’s not really indicated unless they’re

having other alarm symptoms such as dysphagia, odynophagia, and weight loss.”

“Many times we’re called in to do an upper endoscopy … And many times that’s not really indicated unless they’re having other alarm symptoms such as dysphagia, odynophagia, and weight loss.” —Robert Coben, MD

Marcelo Vela, MD, gastroenterologist and hepatologist at the Mayo Clinic in Scottsdale, Ariz., and an associate editor with Clinical Gastroenterology and Hepatology, adds that it’s okay to start a patient with non-cardiac chest pain on PPIs when they have concomitant, typical symptoms of gastroesophageal reflux disease (GERD)—heartburn and acid regurgitation. But in patients without such symptoms, further testing is needed to confirm GERD, he says (Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308–328, Table 1).

This evaluation is usually done in the outpatient setting, he says.

Dr. Vela suggests more care might be needed in the prescribing of PPIs. He says he frequently sees patients who have been hospitalized and put on a PPI without a clear reason.

“They get admitted for various reasons—DVT [deep vein thrombosis], pneumonia, whatever, and then in the hospital, they get started on a proton pump inhibitor for unclear reasons. And then they leave and they stay on it,” Dr. Vela says.

When he asks why, patients just say, “On my last hospitalization, they put me on it,” he says.

“I think you should only leave the hospital on a PPI with a very clear indication—either you found an ulcer or the patient clearly has GERD” or some other reason, he says. “They’re fairly benign medications, but if there’s no indication for it, there’s no benefit.”

Robert Coben, MD, academic coordinator for the Gastrointestinal Fellowship Program at Thomas Jefferson University Hospital in Philadelphia, says that when patients get admitted with chest pain for reasons other than a heart-related problem, he is frequently called on to do an endoscopy right away.

But that’s usually not the best starting point, he says.

“I would say the best test would be to just place the patient on a high-dose proton pump inhibitor once or twice a day first, to see if those symptoms resolve,” he says. “Many times we’re called in to do an upper endoscopy. … And many times that’s not really indicated unless they’re

having other alarm symptoms such as dysphagia, odynophagia, and weight loss.”

“Many times we’re called in to do an upper endoscopy … And many times that’s not really indicated unless they’re having other alarm symptoms such as dysphagia, odynophagia, and weight loss.” —Robert Coben, MD

Marcelo Vela, MD, gastroenterologist and hepatologist at the Mayo Clinic in Scottsdale, Ariz., and an associate editor with Clinical Gastroenterology and Hepatology, adds that it’s okay to start a patient with non-cardiac chest pain on PPIs when they have concomitant, typical symptoms of gastroesophageal reflux disease (GERD)—heartburn and acid regurgitation. But in patients without such symptoms, further testing is needed to confirm GERD, he says (Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308–328, Table 1).

This evaluation is usually done in the outpatient setting, he says.

Dr. Vela suggests more care might be needed in the prescribing of PPIs. He says he frequently sees patients who have been hospitalized and put on a PPI without a clear reason.

“They get admitted for various reasons—DVT [deep vein thrombosis], pneumonia, whatever, and then in the hospital, they get started on a proton pump inhibitor for unclear reasons. And then they leave and they stay on it,” Dr. Vela says.

When he asks why, patients just say, “On my last hospitalization, they put me on it,” he says.

“I think you should only leave the hospital on a PPI with a very clear indication—either you found an ulcer or the patient clearly has GERD” or some other reason, he says. “They’re fairly benign medications, but if there’s no indication for it, there’s no benefit.”

Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?

Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.

Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.

Setting: Fifty-six National Health Service EDs in the United Kingdom.

Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.

Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.

Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?

Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.

Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.

Setting: Fifty-six National Health Service EDs in the United Kingdom.

Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.

Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.

Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Clinical question: Does EGDT for sepsis reduce mortality at 90 days compared with standard therapy?

Background: EGDT is recommended in international guidelines for the resuscitation of patients presenting with early septic shock; however, adoption has been limited, and uncertainty about its effectiveness remains.

Study design: Pragmatic, multicenter, randomized controlled trial (RCT) with intention to treat analysis.

Setting: Fifty-six National Health Service EDs in the United Kingdom.

Synopsis: ProMISe trial enrolled 1,251 patients with severe sepsis or septic shock and patients were randomized to usual-care group (as determined by the treating clinicians) or algorithm-driven EGDT, which included continuous central venous oxygen saturation (ScvO2) using the original EGDT protocol. The primary outcome of all-cause mortality at 90 days was not significantly different between the two groups: 29.5% in EGDT and 29.2% in the usual-care group (P=0.9). This translated into a relative risk of 1.01% (95% CI 0.85-1.20) in the EGDT group. There were no meaningful differences in secondary outcomes.

Both groups in this study were actually well matched for most interventions. The main difference was in the use of continuous ScvO2 measurement and central venous pressure to guide management. Perhaps we should not completely dismiss the term EGDT. Most of our “usual care” consists of early intervention and goal-directed therapy.

Bottom line: In patients identified early with septic shock, the use of EGDT vs. “usual” care did not result in a statistical difference in 90-day mortality.

Citation: Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372:1301-1311.

Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?

Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.

Study design: Systemic literature review and meta-analysis.

Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.

Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.

Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?

Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.

Study design: Systemic literature review and meta-analysis.

Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.

Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.

Clinical question: How effective are multicomponent, nonpharmacological interventions at reducing delirium and preventing poor outcomes?

Background: Delirium is an acute disorder with significant morbidity and mortality. Systemic reviews and clinical guidelines recommend targeted, multicomponent, nonpharmacologic strategies for prevention. The Hospital Elder Life Program (HELP) uses an interdisciplinary team to implement nonpharmacologic interventions, such as reorientation, early mobilization, therapeutic activities, hydration, nutrition, sleep strategies, and hearing and vision adaptation. Trials of nonpharmacological strategies to prevent this disorder have been limited to small-scale studies.

Study design: Systemic literature review and meta-analysis.

Synopsis: Fourteen studies involving 12 unique interventions were identified and results were pooled for meta-analysis, with primary outcomes being incidence and falls. Secondary outcomes were length of stay, institutionalization, and change in functional or cognitive status. Eleven studies were found to have demonstrated significant reductions in delirium incidence (odds ratio [OR], 0.47; 95% CI, 0.38-0.58), with four trials reducing delirium incidence by 44% (OR, 0.56; 95%CI, 0.42-0.76). Four studies demonstrated a significant decrease in the rate of falls (OR, 0.38; 95% CI, 0.25-0.60), with two studies reducing falls by 64% (OR, 0.36; 95% CI, 0.22-0.61). Institutionalization and length of stay did not demonstrate statistical significance between the two groups.

Bottom line: Multicomponent, nonpharmacological delirium prevention interventions were found to be effective in decreasing the occurrence of both delirium and falls during hospitalization in older persons.

Citation: Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions. JAMA. 2015;175(4):512-520.

I am a hospitalist at a small rural hospital, and I’ve read both the hyponatremia and SIADH articles published in The Hospitalist. Our lab does not do any urine testing beyond a UA [urinalysis] in house, so the urine osmol and urine Na+ tests are send-outs, which take several days to come back. I’m having difficulty with diagnosing the reason for and treating hyponatremia. I find it complicated, and when the urine tests are not readily available, it’s difficult to use the algorithm. Do you know of any basic tips that could help? If our hospital does not have the right urine tests readily available, should I be sending these patients to the larger hospital from the ED if sodium is <125, instead of admitting them?

—Carleigh Wilson, DO

Dr. Hospitalist responds:

I too can recall moonlighting in a small rural hospital in southern Georgia 25 years ago; I remember having to improvise when taking care of patients with hyponatremia. Fortunately, even though we have developed more sophisticated equipment to help in the diagnosis (e.g. electrodes that are not hampered by excess triglycerides or proteins), my basic approach to evaluating these patients hasn’t changed much.

I still begin with an assessment of the patients’ serum osmolarity, which is usually low in most hospitalized patients. If it is elevated, then, of course, hyperglycemia is the most common cause, but we also must consider alcohol or, way less common these days, mannitol. Hypoosmolar hyponatremia most often occurs when the kidneys are overwhelmed by the intake of water and cannot excrete it as free water. Even though it can occur when there is pathologic consumption of large amounts of water (psychogenic polydipsia) or excess consumption of beer, it most often occurs when the kidney fails to fully dilute the urine, which would be evidenced by urine osmolality >100mmol/l.

A good history and physical will help categorize the patients with poorly diluted urine; in the absence of measured urine osmolality, however, urine specific gravity (USG) can be used with some caveats. Studies have shown that USG done by refractometry and reagent strip (both very inexpensive) have a correlation of 0.75-0.80 with urine osmolality. Although there are many variables affecting both (pH, ketones, glucose, urobilinogen, bilirubin, and protein for the reagent strips), I would use the refractometer, which only seems to be affected by bilirubin, ketones, and hemoglobin. So, at a pH of 7, with all the variables considered and a USG of 1.010, predicted osmolality is approximately 300 mosm/kg/H20. Also, while osmolarity and specific gravity change in parallel, the two measurements diverge when there are large particles in solution (e.g. glucose or proteins), so be careful … Dr Kokko would be so proud of me!

The next step is to determine the patients’ volume status. Because I’m old school, I still believe this can be done at the bedside. On most occasions, it is only when I’m trying to decide whether the primary sodium loss in hypovolemic patients is due to a renal or extra-renal cause that the urine sodium is helpful. In truly hypovolemic and asymptomatic patients, I usually start with normal saline (NS) to correct the volume status and follow the serum sodium closely to avoid correcting too rapidly. Urine sodium is not particularly helpful in caring for euvolemic and hypervolemic hyponatremic patients.

Due to multiple variables (e.g. acute vs. chronic, co-morbidities, nursing and lab support, quick and safe transfer to higher level of care), it is difficult to quantify a “safe” level of hyponatremia to treat at a small rural hospital. Considering the clinical variables and presence of symptoms, I probably would not be comfortable with a serum sodium less than 123 meq/L. However, you have to understand and appreciate your limitations and develop your own level of comfort.

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

I am a hospitalist at a small rural hospital, and I’ve read both the hyponatremia and SIADH articles published in The Hospitalist. Our lab does not do any urine testing beyond a UA [urinalysis] in house, so the urine osmol and urine Na+ tests are send-outs, which take several days to come back. I’m having difficulty with diagnosing the reason for and treating hyponatremia. I find it complicated, and when the urine tests are not readily available, it’s difficult to use the algorithm. Do you know of any basic tips that could help? If our hospital does not have the right urine tests readily available, should I be sending these patients to the larger hospital from the ED if sodium is <125, instead of admitting them?

—Carleigh Wilson, DO

Dr. Hospitalist responds:

I too can recall moonlighting in a small rural hospital in southern Georgia 25 years ago; I remember having to improvise when taking care of patients with hyponatremia. Fortunately, even though we have developed more sophisticated equipment to help in the diagnosis (e.g. electrodes that are not hampered by excess triglycerides or proteins), my basic approach to evaluating these patients hasn’t changed much.

I still begin with an assessment of the patients’ serum osmolarity, which is usually low in most hospitalized patients. If it is elevated, then, of course, hyperglycemia is the most common cause, but we also must consider alcohol or, way less common these days, mannitol. Hypoosmolar hyponatremia most often occurs when the kidneys are overwhelmed by the intake of water and cannot excrete it as free water. Even though it can occur when there is pathologic consumption of large amounts of water (psychogenic polydipsia) or excess consumption of beer, it most often occurs when the kidney fails to fully dilute the urine, which would be evidenced by urine osmolality >100mmol/l.

A good history and physical will help categorize the patients with poorly diluted urine; in the absence of measured urine osmolality, however, urine specific gravity (USG) can be used with some caveats. Studies have shown that USG done by refractometry and reagent strip (both very inexpensive) have a correlation of 0.75-0.80 with urine osmolality. Although there are many variables affecting both (pH, ketones, glucose, urobilinogen, bilirubin, and protein for the reagent strips), I would use the refractometer, which only seems to be affected by bilirubin, ketones, and hemoglobin. So, at a pH of 7, with all the variables considered and a USG of 1.010, predicted osmolality is approximately 300 mosm/kg/H20. Also, while osmolarity and specific gravity change in parallel, the two measurements diverge when there are large particles in solution (e.g. glucose or proteins), so be careful … Dr Kokko would be so proud of me!

The next step is to determine the patients’ volume status. Because I’m old school, I still believe this can be done at the bedside. On most occasions, it is only when I’m trying to decide whether the primary sodium loss in hypovolemic patients is due to a renal or extra-renal cause that the urine sodium is helpful. In truly hypovolemic and asymptomatic patients, I usually start with normal saline (NS) to correct the volume status and follow the serum sodium closely to avoid correcting too rapidly. Urine sodium is not particularly helpful in caring for euvolemic and hypervolemic hyponatremic patients.

Due to multiple variables (e.g. acute vs. chronic, co-morbidities, nursing and lab support, quick and safe transfer to higher level of care), it is difficult to quantify a “safe” level of hyponatremia to treat at a small rural hospital. Considering the clinical variables and presence of symptoms, I probably would not be comfortable with a serum sodium less than 123 meq/L. However, you have to understand and appreciate your limitations and develop your own level of comfort.

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

I am a hospitalist at a small rural hospital, and I’ve read both the hyponatremia and SIADH articles published in The Hospitalist. Our lab does not do any urine testing beyond a UA [urinalysis] in house, so the urine osmol and urine Na+ tests are send-outs, which take several days to come back. I’m having difficulty with diagnosing the reason for and treating hyponatremia. I find it complicated, and when the urine tests are not readily available, it’s difficult to use the algorithm. Do you know of any basic tips that could help? If our hospital does not have the right urine tests readily available, should I be sending these patients to the larger hospital from the ED if sodium is <125, instead of admitting them?

—Carleigh Wilson, DO

Dr. Hospitalist responds:

I too can recall moonlighting in a small rural hospital in southern Georgia 25 years ago; I remember having to improvise when taking care of patients with hyponatremia. Fortunately, even though we have developed more sophisticated equipment to help in the diagnosis (e.g. electrodes that are not hampered by excess triglycerides or proteins), my basic approach to evaluating these patients hasn’t changed much.

I still begin with an assessment of the patients’ serum osmolarity, which is usually low in most hospitalized patients. If it is elevated, then, of course, hyperglycemia is the most common cause, but we also must consider alcohol or, way less common these days, mannitol. Hypoosmolar hyponatremia most often occurs when the kidneys are overwhelmed by the intake of water and cannot excrete it as free water. Even though it can occur when there is pathologic consumption of large amounts of water (psychogenic polydipsia) or excess consumption of beer, it most often occurs when the kidney fails to fully dilute the urine, which would be evidenced by urine osmolality >100mmol/l.

A good history and physical will help categorize the patients with poorly diluted urine; in the absence of measured urine osmolality, however, urine specific gravity (USG) can be used with some caveats. Studies have shown that USG done by refractometry and reagent strip (both very inexpensive) have a correlation of 0.75-0.80 with urine osmolality. Although there are many variables affecting both (pH, ketones, glucose, urobilinogen, bilirubin, and protein for the reagent strips), I would use the refractometer, which only seems to be affected by bilirubin, ketones, and hemoglobin. So, at a pH of 7, with all the variables considered and a USG of 1.010, predicted osmolality is approximately 300 mosm/kg/H20. Also, while osmolarity and specific gravity change in parallel, the two measurements diverge when there are large particles in solution (e.g. glucose or proteins), so be careful … Dr Kokko would be so proud of me!

The next step is to determine the patients’ volume status. Because I’m old school, I still believe this can be done at the bedside. On most occasions, it is only when I’m trying to decide whether the primary sodium loss in hypovolemic patients is due to a renal or extra-renal cause that the urine sodium is helpful. In truly hypovolemic and asymptomatic patients, I usually start with normal saline (NS) to correct the volume status and follow the serum sodium closely to avoid correcting too rapidly. Urine sodium is not particularly helpful in caring for euvolemic and hypervolemic hyponatremic patients.

Due to multiple variables (e.g. acute vs. chronic, co-morbidities, nursing and lab support, quick and safe transfer to higher level of care), it is difficult to quantify a “safe” level of hyponatremia to treat at a small rural hospital. Considering the clinical variables and presence of symptoms, I probably would not be comfortable with a serum sodium less than 123 meq/L. However, you have to understand and appreciate your limitations and develop your own level of comfort.

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

We are definitely in the era of data access and transparency. These days you can find information on anything and everything within a matter of seconds. You can become a subject matter expert on any topic within a matter of hours: music, cooking, foreign language, weather, travel. The possibilities are endless. That is, unless you want information on yourself—specifically, medical information.

Despite all of our advances in technology in the information era, many patients still find it extremely difficult and frustrating to gain full and transparent access to their medical records. Electronic health records (EHRs) have made it easier than ever for practitioners to find information about their patients, including pharmacy and access queries to determine what medications they are (or are not) taking, and where they have recently accessed care. But EHRs have not been widely utilized as a tool to grant extensive, real-time access to patients.

But change is afoot. Both providers and patients are now realizing the value of offering patients more open access to their medical records. Many organizations with EHRs have created patient portals, where patients can access limited portions of their medical records such as medications and allergies, can request items such as prescription refills or appointments, and can ask their providers about their care. Some medical centers are participating in OpenNotes initiatives, which give patients direct access to provider notes within the medical record.

Although these patient portals are a great first step in transparency and engagement, the information granted to patients is limited in content and timeliness. Generally, such items as test results must first be “released” by a provider before they can be viewed by the patient; some organizations have set restrictions, determining that some tests cannot be released at all (i.e., abnormal pathology or HIV test results). The rationale for such restrictions is to prevent patients from finding out sensitive information from a web page; many assume that the patient would be much better off finding out such information from a provider than a computer, and that well may be true, if the information is available in a timely fashion and is shared by a provider who can relay the information better than a computer.

Barriers Aplenty

The medical industry still has a long way to go to realize full medical record transparency for patients. One legitimate barrier is that medical records were never intended for patient view or use. Most do not read like a story; they read more like a ledger, full of medical jargon and text boxes in illogical order. This is primarily due to the fact that EHRs were designed for regulatory and billing purposes, not to eloquently—or even adequately—summarize what the patient is (or was) experiencing.

Another major barrier is that the information in the medical record is often difficult to find, and the record itself is difficult to maneuver. Experienced and trained providers, even those who have dutifully completed medical training, often find it challenging to locate exactly what they are looking for. The burden would be on the patient to learn, understand, and navigate the medical record, and few would likely undertake such a challenge.

There also are legitimate cultural barriers among providers, who will resist giving patients carte blanche access to the EHR; many providers cite concerns that if they honestly summarize sensitive information in the medical record (i.e., social habits or medication compliance issues), patients may be angered, with resultant loss of trust, retaliation, or legal action.

Clear the Hurdles, and Next Steps

There is a great story about how well medical record transparency can work, summarized in a New York Times article a few months ago.¹ The story tells of 26-year-old Steven Keating, who had a “slight abnormality” on a brain CT that was done in 2007 as part of a study he had volunteered for.² Although reassured by a “normal” follow-up scan in 2010, Keating was inquisitive, wanting to understand everything about his condition, and read voraciously about what his initial brain scan could mean. He knew the initial abnormality was near his olfactory nerve, so in 2014, when he started intermittently smelling vinegar, he suspected it might be related to the abnormality noted in his initial scan.

He sought immediate care and follow-up imaging, which showed a very large mass. Within weeks, this large astrocytoma was successfully removed; surgery was followed by chemotherapy and radiation.

Over the course of Keating’s care, he amassed more than 70 gigabytes of medical information about himself, including 10 hours of video footage from his initial surgery. Throughout the course of his illness, he remained eager to obtain all facets of his medical information, including such videos and scans, and considered these pieces of information critical to his healing process. He found that, in general, when he asked doctors to share information, he was usually granted access to what he wanted and needed, but the onus was always on him to ask. At one point he asked, “How come there isn’t a ‘share’ button at the hospital?”

Steven now has an entire website dedicated to his personal healthcare story, coupled with a passionate plea to enhance open access to medical records.² He writes: “I have become passionate about open-sourcing the data and how we can learn through sharing. … Patients can collect their own data and they should be able to share it, amongst patients, communities, and to benefit science if desired. Healthcare should be a two-way road, patients alongside doctors and researchers as a team. The future will be driven by networked healthcare, support communities, and, I believe, patient curiosity.”

Steven was able to cobble together his medical record better than most others could, as he definitely has some advantages over many other patients; he is young, articulate, bright, and highly educated. It would be much more difficult for an older, less well educated, or disenfranchised patient to accomplish this level of understanding of and engagement in the current system. “The person with the least access to data in the system is the patient,” he writes on his website. “You can get it, but the burden is always on the patient. And it is scattered across many different silos of patient data.”

Providers and patients alike should insist on more transparency, coupled with better and more streamlined communication. As patients become more agile at maneuvering through the web portals and more engaged in their care, patients and providers gain innumerable advantages. Patients could help to find any and all medical record information that is incorrect or inconsistent, working to ensure the accuracy of the content—and get rid of “chart lore.” They could fill in missing content and update information between visits, such as changes to their social history or demographics. This is all very good timing, given the recent shift to pay for performance and population health; as financial incentives are veering away from fee for service, it is becoming more profitable to help patients stay well than to keep them sick.

As hospitalists, we should look forward to these advances in technology to enhance access to information for ourselves and for our patients. We should seek out mechanisms within our organization to enhance the speed at which open access for patients is granted, to improve patient engagement throughout the spectrum of their care.

References

1. Lohr S. The healing power of your own medical records. March 31, 2015. The New York Times website.. Accessed June 1, 2015.
2. Keating S. Steven Keating homepage. Accessed June 1, 2015.

We are definitely in the era of data access and transparency. These days you can find information on anything and everything within a matter of seconds. You can become a subject matter expert on any topic within a matter of hours: music, cooking, foreign language, weather, travel. The possibilities are endless. That is, unless you want information on yourself—specifically, medical information.

Despite all of our advances in technology in the information era, many patients still find it extremely difficult and frustrating to gain full and transparent access to their medical records. Electronic health records (EHRs) have made it easier than ever for practitioners to find information about their patients, including pharmacy and access queries to determine what medications they are (or are not) taking, and where they have recently accessed care. But EHRs have not been widely utilized as a tool to grant extensive, real-time access to patients.

But change is afoot. Both providers and patients are now realizing the value of offering patients more open access to their medical records. Many organizations with EHRs have created patient portals, where patients can access limited portions of their medical records such as medications and allergies, can request items such as prescription refills or appointments, and can ask their providers about their care. Some medical centers are participating in OpenNotes initiatives, which give patients direct access to provider notes within the medical record.

Although these patient portals are a great first step in transparency and engagement, the information granted to patients is limited in content and timeliness. Generally, such items as test results must first be “released” by a provider before they can be viewed by the patient; some organizations have set restrictions, determining that some tests cannot be released at all (i.e., abnormal pathology or HIV test results). The rationale for such restrictions is to prevent patients from finding out sensitive information from a web page; many assume that the patient would be much better off finding out such information from a provider than a computer, and that well may be true, if the information is available in a timely fashion and is shared by a provider who can relay the information better than a computer.

Barriers Aplenty

The medical industry still has a long way to go to realize full medical record transparency for patients. One legitimate barrier is that medical records were never intended for patient view or use. Most do not read like a story; they read more like a ledger, full of medical jargon and text boxes in illogical order. This is primarily due to the fact that EHRs were designed for regulatory and billing purposes, not to eloquently—or even adequately—summarize what the patient is (or was) experiencing.

Another major barrier is that the information in the medical record is often difficult to find, and the record itself is difficult to maneuver. Experienced and trained providers, even those who have dutifully completed medical training, often find it challenging to locate exactly what they are looking for. The burden would be on the patient to learn, understand, and navigate the medical record, and few would likely undertake such a challenge.

There also are legitimate cultural barriers among providers, who will resist giving patients carte blanche access to the EHR; many providers cite concerns that if they honestly summarize sensitive information in the medical record (i.e., social habits or medication compliance issues), patients may be angered, with resultant loss of trust, retaliation, or legal action.

Clear the Hurdles, and Next Steps

There is a great story about how well medical record transparency can work, summarized in a New York Times article a few months ago.¹ The story tells of 26-year-old Steven Keating, who had a “slight abnormality” on a brain CT that was done in 2007 as part of a study he had volunteered for.² Although reassured by a “normal” follow-up scan in 2010, Keating was inquisitive, wanting to understand everything about his condition, and read voraciously about what his initial brain scan could mean. He knew the initial abnormality was near his olfactory nerve, so in 2014, when he started intermittently smelling vinegar, he suspected it might be related to the abnormality noted in his initial scan.

He sought immediate care and follow-up imaging, which showed a very large mass. Within weeks, this large astrocytoma was successfully removed; surgery was followed by chemotherapy and radiation.

Over the course of Keating’s care, he amassed more than 70 gigabytes of medical information about himself, including 10 hours of video footage from his initial surgery. Throughout the course of his illness, he remained eager to obtain all facets of his medical information, including such videos and scans, and considered these pieces of information critical to his healing process. He found that, in general, when he asked doctors to share information, he was usually granted access to what he wanted and needed, but the onus was always on him to ask. At one point he asked, “How come there isn’t a ‘share’ button at the hospital?”

Steven now has an entire website dedicated to his personal healthcare story, coupled with a passionate plea to enhance open access to medical records.² He writes: “I have become passionate about open-sourcing the data and how we can learn through sharing. … Patients can collect their own data and they should be able to share it, amongst patients, communities, and to benefit science if desired. Healthcare should be a two-way road, patients alongside doctors and researchers as a team. The future will be driven by networked healthcare, support communities, and, I believe, patient curiosity.”

Steven was able to cobble together his medical record better than most others could, as he definitely has some advantages over many other patients; he is young, articulate, bright, and highly educated. It would be much more difficult for an older, less well educated, or disenfranchised patient to accomplish this level of understanding of and engagement in the current system. “The person with the least access to data in the system is the patient,” he writes on his website. “You can get it, but the burden is always on the patient. And it is scattered across many different silos of patient data.”

Providers and patients alike should insist on more transparency, coupled with better and more streamlined communication. As patients become more agile at maneuvering through the web portals and more engaged in their care, patients and providers gain innumerable advantages. Patients could help to find any and all medical record information that is incorrect or inconsistent, working to ensure the accuracy of the content—and get rid of “chart lore.” They could fill in missing content and update information between visits, such as changes to their social history or demographics. This is all very good timing, given the recent shift to pay for performance and population health; as financial incentives are veering away from fee for service, it is becoming more profitable to help patients stay well than to keep them sick.

As hospitalists, we should look forward to these advances in technology to enhance access to information for ourselves and for our patients. We should seek out mechanisms within our organization to enhance the speed at which open access for patients is granted, to improve patient engagement throughout the spectrum of their care.

References

1. Lohr S. The healing power of your own medical records. March 31, 2015. The New York Times website.. Accessed June 1, 2015.
2. Keating S. Steven Keating homepage. Accessed June 1, 2015.

We are definitely in the era of data access and transparency. These days you can find information on anything and everything within a matter of seconds. You can become a subject matter expert on any topic within a matter of hours: music, cooking, foreign language, weather, travel. The possibilities are endless. That is, unless you want information on yourself—specifically, medical information.

Despite all of our advances in technology in the information era, many patients still find it extremely difficult and frustrating to gain full and transparent access to their medical records. Electronic health records (EHRs) have made it easier than ever for practitioners to find information about their patients, including pharmacy and access queries to determine what medications they are (or are not) taking, and where they have recently accessed care. But EHRs have not been widely utilized as a tool to grant extensive, real-time access to patients.

But change is afoot. Both providers and patients are now realizing the value of offering patients more open access to their medical records. Many organizations with EHRs have created patient portals, where patients can access limited portions of their medical records such as medications and allergies, can request items such as prescription refills or appointments, and can ask their providers about their care. Some medical centers are participating in OpenNotes initiatives, which give patients direct access to provider notes within the medical record.

Although these patient portals are a great first step in transparency and engagement, the information granted to patients is limited in content and timeliness. Generally, such items as test results must first be “released” by a provider before they can be viewed by the patient; some organizations have set restrictions, determining that some tests cannot be released at all (i.e., abnormal pathology or HIV test results). The rationale for such restrictions is to prevent patients from finding out sensitive information from a web page; many assume that the patient would be much better off finding out such information from a provider than a computer, and that well may be true, if the information is available in a timely fashion and is shared by a provider who can relay the information better than a computer.

Barriers Aplenty

The medical industry still has a long way to go to realize full medical record transparency for patients. One legitimate barrier is that medical records were never intended for patient view or use. Most do not read like a story; they read more like a ledger, full of medical jargon and text boxes in illogical order. This is primarily due to the fact that EHRs were designed for regulatory and billing purposes, not to eloquently—or even adequately—summarize what the patient is (or was) experiencing.

Another major barrier is that the information in the medical record is often difficult to find, and the record itself is difficult to maneuver. Experienced and trained providers, even those who have dutifully completed medical training, often find it challenging to locate exactly what they are looking for. The burden would be on the patient to learn, understand, and navigate the medical record, and few would likely undertake such a challenge.

There also are legitimate cultural barriers among providers, who will resist giving patients carte blanche access to the EHR; many providers cite concerns that if they honestly summarize sensitive information in the medical record (i.e., social habits or medication compliance issues), patients may be angered, with resultant loss of trust, retaliation, or legal action.

Clear the Hurdles, and Next Steps

There is a great story about how well medical record transparency can work, summarized in a New York Times article a few months ago.¹ The story tells of 26-year-old Steven Keating, who had a “slight abnormality” on a brain CT that was done in 2007 as part of a study he had volunteered for.² Although reassured by a “normal” follow-up scan in 2010, Keating was inquisitive, wanting to understand everything about his condition, and read voraciously about what his initial brain scan could mean. He knew the initial abnormality was near his olfactory nerve, so in 2014, when he started intermittently smelling vinegar, he suspected it might be related to the abnormality noted in his initial scan.

He sought immediate care and follow-up imaging, which showed a very large mass. Within weeks, this large astrocytoma was successfully removed; surgery was followed by chemotherapy and radiation.

Over the course of Keating’s care, he amassed more than 70 gigabytes of medical information about himself, including 10 hours of video footage from his initial surgery. Throughout the course of his illness, he remained eager to obtain all facets of his medical information, including such videos and scans, and considered these pieces of information critical to his healing process. He found that, in general, when he asked doctors to share information, he was usually granted access to what he wanted and needed, but the onus was always on him to ask. At one point he asked, “How come there isn’t a ‘share’ button at the hospital?”

Steven now has an entire website dedicated to his personal healthcare story, coupled with a passionate plea to enhance open access to medical records.² He writes: “I have become passionate about open-sourcing the data and how we can learn through sharing. … Patients can collect their own data and they should be able to share it, amongst patients, communities, and to benefit science if desired. Healthcare should be a two-way road, patients alongside doctors and researchers as a team. The future will be driven by networked healthcare, support communities, and, I believe, patient curiosity.”

Steven was able to cobble together his medical record better than most others could, as he definitely has some advantages over many other patients; he is young, articulate, bright, and highly educated. It would be much more difficult for an older, less well educated, or disenfranchised patient to accomplish this level of understanding of and engagement in the current system. “The person with the least access to data in the system is the patient,” he writes on his website. “You can get it, but the burden is always on the patient. And it is scattered across many different silos of patient data.”

Providers and patients alike should insist on more transparency, coupled with better and more streamlined communication. As patients become more agile at maneuvering through the web portals and more engaged in their care, patients and providers gain innumerable advantages. Patients could help to find any and all medical record information that is incorrect or inconsistent, working to ensure the accuracy of the content—and get rid of “chart lore.” They could fill in missing content and update information between visits, such as changes to their social history or demographics. This is all very good timing, given the recent shift to pay for performance and population health; as financial incentives are veering away from fee for service, it is becoming more profitable to help patients stay well than to keep them sick.

As hospitalists, we should look forward to these advances in technology to enhance access to information for ourselves and for our patients. We should seek out mechanisms within our organization to enhance the speed at which open access for patients is granted, to improve patient engagement throughout the spectrum of their care.

References

1. Lohr S. The healing power of your own medical records. March 31, 2015. The New York Times website.. Accessed June 1, 2015.
2. Keating S. Steven Keating homepage. Accessed June 1, 2015.

The musty collections of National Geographic magazines once found in so many basements are largely gone. Replacing them are dusty sets of the Advisory Board binders and booklets found in hospital administration offices around the country. I think the same principle drives the impulse to collect both publications—the idea that they contain worthwhile information that one day will be reviewed. But I think it’s more likely they will be ignored until it is time to move and someone has to decide what to do with the painfully heavy pile of paper.

Lots of old and largely forgotten things are making a comeback in healthcare. I suppose this is always happening, but I sense we’re now experiencing more of this than usual. It’s a renaissance of sorts.

I first heard about fecal transplant for Clostridium difficile infection (instilling a “better” microbiome in the hope of realizing many benefits) about six or eight years ago. Although I was sure this was a new idea, my retired internist father told me this had been around when he was in training. Wikipedia says that four Colorado surgeons published a paper about it in 1958 and that the Chinese were doing this 1,600 years ago.

PCPs Visit Hospitalized Patients

Writing in the NEJM earlier this year, Goroll and Hunt proposed that primary care physicians visit their hospitalized patients in the role of consultant while the hospitalist remains attending. As they note, this idea surfaced as soon as the hospitalist model began taking hold. Back then, we usually referred to it as a “social visit” by the PCP. Anecdotal experience from my work with hundreds of hospitalist groups tells me that such visits have all but disappeared. But nearly every such PCP visit on a patient I’ve cared for has seemed worthwhile; in many cases, these hospital calls simply reassure a nervous patient or family member, and occasionally they ensure that the PCP and I arrive at a more effective plan of care than we might otherwise.

Perhaps new forms of healthcare reimbursement, accountable care, and population health may make “continuity visits” economically viable for PCPs. Wouldn’t it be interesting if PCP visits to hospitalized patients and hospitalist visits to outpatients, such as those occurring in a pre-op clinic or a skilled nursing facility, become commonplace? The trick in all of this will be to ensure the right amount of overlap, or shared visits, between PCP and hospitalist without expensive duplication of effort or errors stemming from too many cooks in the kitchen.

Post-Hospital Follow-Up Schedules

When I began practicing as a hospitalist in the 1980s, doctors routinely wrote orders similar to this one: “Have patient follow up with Dr. Smith (PCP or specialist) in 1-2 weeks.” The unit secretary or other hospital clerical staff would contact the physician’s office to schedule the appointment, and the patient would leave the hospital with a written reminder in hand. My sense is that nearly all hospitals had been doing this for decades; somehow this practice has nearly disappeared over the last 10-20 years, however, and I sometimes hear this old practice discussed as a new idea.

I think making sure the patient has a follow-up appointment in hand when leaving the hospital is likely good for clinical outcomes, readmissions, and patient satisfaction. In my view, it is hardly worth lots of research to prove the benefit of what should be a relatively low-cost intervention. Why not just have providers write orders detailing follow-up with a specific doctor or clinic and a timeframe, and have unit secretaries communicate with outpatient clinics to schedule the appointments and ensure that the details are provided to the patient, maybe via an EHR-generated after visit summary? Seems pretty easy, right?

Turns out it isn’t easy at all for most hospitals. Lots of energetic hospitalists have taken on a project like this, only to run into so many brick walls. One hospitalist told me recently that the unit secretary’s labor union at her hospital refused to allow it. So some hospitals have turned to a single person, or a small group of people, who make appointments for all hospital patients. Some hospitalist groups have one of their own staff make appointments for hospitalist patients. This relieves the unit secretaries of the task but requires additional funding for the salaries of these people.

Maybe, at some time not so far off, EHRs will be so user-friendly and patients/families so accustomed to using them that it will be common for patients/families to arrange the appointments on their own. It could even be a required step—a hard stop—in the discharge process.

Whatever emerges as the most common method of making these appointments, I think it is safe to say this old practice will become “new” and common within the next few years.

Multidisciplinary Rounds

While working as an orderly in the 1970s, I would often visit with the nurses in their break room. When a doctor arrived to make rounds on the floor, the RN would jump up, stub out her cigarette, and round with the doctor. I sometimes tagged along as an observer. The nurse let the doctor know just how the patient had been doing and provided test results and any other relevant information the doctor might need. The doctor would provide orders, and sometimes the nurse wrote them into the chart (think of today’s medical scribes). Although their interaction was much less collaborative than is typical today, they did ask lots of questions of one another to clarify ambiguities.

I think these 1970s caregivers were doing effective multidisciplinary rounds. But by the late 1980s or so, as both doctor and nurse became busier, they stopped rounding together.

I smile when I hear descriptions of this “new” idea of doctor and nurse (and often other caregivers) rounding together. Today’s hospital culture is less hierarchical than the 1970s, though some would say it still has a ways to go, so teamwork and multidisciplinary rounds may yield more benefit than decades ago. But the idea of rounding together certainly isn’t new.

As we try to figure out the best way to thrive in a rapidly changing healthcare environment, we may find value in returning to the old ways of doing some things.

The musty collections of National Geographic magazines once found in so many basements are largely gone. Replacing them are dusty sets of the Advisory Board binders and booklets found in hospital administration offices around the country. I think the same principle drives the impulse to collect both publications—the idea that they contain worthwhile information that one day will be reviewed. But I think it’s more likely they will be ignored until it is time to move and someone has to decide what to do with the painfully heavy pile of paper.

Lots of old and largely forgotten things are making a comeback in healthcare. I suppose this is always happening, but I sense we’re now experiencing more of this than usual. It’s a renaissance of sorts.

I first heard about fecal transplant for Clostridium difficile infection (instilling a “better” microbiome in the hope of realizing many benefits) about six or eight years ago. Although I was sure this was a new idea, my retired internist father told me this had been around when he was in training. Wikipedia says that four Colorado surgeons published a paper about it in 1958 and that the Chinese were doing this 1,600 years ago.

PCPs Visit Hospitalized Patients

Writing in the NEJM earlier this year, Goroll and Hunt proposed that primary care physicians visit their hospitalized patients in the role of consultant while the hospitalist remains attending. As they note, this idea surfaced as soon as the hospitalist model began taking hold. Back then, we usually referred to it as a “social visit” by the PCP. Anecdotal experience from my work with hundreds of hospitalist groups tells me that such visits have all but disappeared. But nearly every such PCP visit on a patient I’ve cared for has seemed worthwhile; in many cases, these hospital calls simply reassure a nervous patient or family member, and occasionally they ensure that the PCP and I arrive at a more effective plan of care than we might otherwise.

Perhaps new forms of healthcare reimbursement, accountable care, and population health may make “continuity visits” economically viable for PCPs. Wouldn’t it be interesting if PCP visits to hospitalized patients and hospitalist visits to outpatients, such as those occurring in a pre-op clinic or a skilled nursing facility, become commonplace? The trick in all of this will be to ensure the right amount of overlap, or shared visits, between PCP and hospitalist without expensive duplication of effort or errors stemming from too many cooks in the kitchen.

Post-Hospital Follow-Up Schedules

When I began practicing as a hospitalist in the 1980s, doctors routinely wrote orders similar to this one: “Have patient follow up with Dr. Smith (PCP or specialist) in 1-2 weeks.” The unit secretary or other hospital clerical staff would contact the physician’s office to schedule the appointment, and the patient would leave the hospital with a written reminder in hand. My sense is that nearly all hospitals had been doing this for decades; somehow this practice has nearly disappeared over the last 10-20 years, however, and I sometimes hear this old practice discussed as a new idea.

I think making sure the patient has a follow-up appointment in hand when leaving the hospital is likely good for clinical outcomes, readmissions, and patient satisfaction. In my view, it is hardly worth lots of research to prove the benefit of what should be a relatively low-cost intervention. Why not just have providers write orders detailing follow-up with a specific doctor or clinic and a timeframe, and have unit secretaries communicate with outpatient clinics to schedule the appointments and ensure that the details are provided to the patient, maybe via an EHR-generated after visit summary? Seems pretty easy, right?

Turns out it isn’t easy at all for most hospitals. Lots of energetic hospitalists have taken on a project like this, only to run into so many brick walls. One hospitalist told me recently that the unit secretary’s labor union at her hospital refused to allow it. So some hospitals have turned to a single person, or a small group of people, who make appointments for all hospital patients. Some hospitalist groups have one of their own staff make appointments for hospitalist patients. This relieves the unit secretaries of the task but requires additional funding for the salaries of these people.

Maybe, at some time not so far off, EHRs will be so user-friendly and patients/families so accustomed to using them that it will be common for patients/families to arrange the appointments on their own. It could even be a required step—a hard stop—in the discharge process.

Whatever emerges as the most common method of making these appointments, I think it is safe to say this old practice will become “new” and common within the next few years.

Multidisciplinary Rounds

While working as an orderly in the 1970s, I would often visit with the nurses in their break room. When a doctor arrived to make rounds on the floor, the RN would jump up, stub out her cigarette, and round with the doctor. I sometimes tagged along as an observer. The nurse let the doctor know just how the patient had been doing and provided test results and any other relevant information the doctor might need. The doctor would provide orders, and sometimes the nurse wrote them into the chart (think of today’s medical scribes). Although their interaction was much less collaborative than is typical today, they did ask lots of questions of one another to clarify ambiguities.

I think these 1970s caregivers were doing effective multidisciplinary rounds. But by the late 1980s or so, as both doctor and nurse became busier, they stopped rounding together.

I smile when I hear descriptions of this “new” idea of doctor and nurse (and often other caregivers) rounding together. Today’s hospital culture is less hierarchical than the 1970s, though some would say it still has a ways to go, so teamwork and multidisciplinary rounds may yield more benefit than decades ago. But the idea of rounding together certainly isn’t new.

As we try to figure out the best way to thrive in a rapidly changing healthcare environment, we may find value in returning to the old ways of doing some things.

The musty collections of National Geographic magazines once found in so many basements are largely gone. Replacing them are dusty sets of the Advisory Board binders and booklets found in hospital administration offices around the country. I think the same principle drives the impulse to collect both publications—the idea that they contain worthwhile information that one day will be reviewed. But I think it’s more likely they will be ignored until it is time to move and someone has to decide what to do with the painfully heavy pile of paper.

Lots of old and largely forgotten things are making a comeback in healthcare. I suppose this is always happening, but I sense we’re now experiencing more of this than usual. It’s a renaissance of sorts.

I first heard about fecal transplant for Clostridium difficile infection (instilling a “better” microbiome in the hope of realizing many benefits) about six or eight years ago. Although I was sure this was a new idea, my retired internist father told me this had been around when he was in training. Wikipedia says that four Colorado surgeons published a paper about it in 1958 and that the Chinese were doing this 1,600 years ago.

PCPs Visit Hospitalized Patients

Writing in the NEJM earlier this year, Goroll and Hunt proposed that primary care physicians visit their hospitalized patients in the role of consultant while the hospitalist remains attending. As they note, this idea surfaced as soon as the hospitalist model began taking hold. Back then, we usually referred to it as a “social visit” by the PCP. Anecdotal experience from my work with hundreds of hospitalist groups tells me that such visits have all but disappeared. But nearly every such PCP visit on a patient I’ve cared for has seemed worthwhile; in many cases, these hospital calls simply reassure a nervous patient or family member, and occasionally they ensure that the PCP and I arrive at a more effective plan of care than we might otherwise.

Perhaps new forms of healthcare reimbursement, accountable care, and population health may make “continuity visits” economically viable for PCPs. Wouldn’t it be interesting if PCP visits to hospitalized patients and hospitalist visits to outpatients, such as those occurring in a pre-op clinic or a skilled nursing facility, become commonplace? The trick in all of this will be to ensure the right amount of overlap, or shared visits, between PCP and hospitalist without expensive duplication of effort or errors stemming from too many cooks in the kitchen.

Post-Hospital Follow-Up Schedules

When I began practicing as a hospitalist in the 1980s, doctors routinely wrote orders similar to this one: “Have patient follow up with Dr. Smith (PCP or specialist) in 1-2 weeks.” The unit secretary or other hospital clerical staff would contact the physician’s office to schedule the appointment, and the patient would leave the hospital with a written reminder in hand. My sense is that nearly all hospitals had been doing this for decades; somehow this practice has nearly disappeared over the last 10-20 years, however, and I sometimes hear this old practice discussed as a new idea.

I think making sure the patient has a follow-up appointment in hand when leaving the hospital is likely good for clinical outcomes, readmissions, and patient satisfaction. In my view, it is hardly worth lots of research to prove the benefit of what should be a relatively low-cost intervention. Why not just have providers write orders detailing follow-up with a specific doctor or clinic and a timeframe, and have unit secretaries communicate with outpatient clinics to schedule the appointments and ensure that the details are provided to the patient, maybe via an EHR-generated after visit summary? Seems pretty easy, right?

Turns out it isn’t easy at all for most hospitals. Lots of energetic hospitalists have taken on a project like this, only to run into so many brick walls. One hospitalist told me recently that the unit secretary’s labor union at her hospital refused to allow it. So some hospitals have turned to a single person, or a small group of people, who make appointments for all hospital patients. Some hospitalist groups have one of their own staff make appointments for hospitalist patients. This relieves the unit secretaries of the task but requires additional funding for the salaries of these people.

Maybe, at some time not so far off, EHRs will be so user-friendly and patients/families so accustomed to using them that it will be common for patients/families to arrange the appointments on their own. It could even be a required step—a hard stop—in the discharge process.

Whatever emerges as the most common method of making these appointments, I think it is safe to say this old practice will become “new” and common within the next few years.

Multidisciplinary Rounds

While working as an orderly in the 1970s, I would often visit with the nurses in their break room. When a doctor arrived to make rounds on the floor, the RN would jump up, stub out her cigarette, and round with the doctor. I sometimes tagged along as an observer. The nurse let the doctor know just how the patient had been doing and provided test results and any other relevant information the doctor might need. The doctor would provide orders, and sometimes the nurse wrote them into the chart (think of today’s medical scribes). Although their interaction was much less collaborative than is typical today, they did ask lots of questions of one another to clarify ambiguities.

I think these 1970s caregivers were doing effective multidisciplinary rounds. But by the late 1980s or so, as both doctor and nurse became busier, they stopped rounding together.

I smile when I hear descriptions of this “new” idea of doctor and nurse (and often other caregivers) rounding together. Today’s hospital culture is less hierarchical than the 1970s, though some would say it still has a ways to go, so teamwork and multidisciplinary rounds may yield more benefit than decades ago. But the idea of rounding together certainly isn’t new.

As we try to figure out the best way to thrive in a rapidly changing healthcare environment, we may find value in returning to the old ways of doing some things.

As a hospitalist myself, I have seen firsthand the need for a healthcare system that provides better care, spends dollars more wisely, and keeps people healthier. I practice on weekends taking care of children, many of whom have multiple chronic conditions and fragile social support, and their families. I love patient care; however, too many times, we hospitalists see patients whose fragmented care results in poor outcomes and repeated hospitalizations.

In my current role at the Centers for Medicare and Medicaid Services (CMS), I am pleased to see that Secretary Burwell is confronting these problems head on, with concrete goals for shifting the equation in how we pay for care. Specifically, we announced the goal of moving 30% of payments by 2016 into alternative payment models such as accountable care organizations (ACOs) or bundled payments, where the provider is accountable for total cost of care and quality. We set the goal of 50% of payments in these models by 2018. In 2011, Medicare had essentially zero payments in these models, but by 2014, we have reached 20% and growing in alternative payment models. Hospitalists can play a significant role in this healthcare transformation, and several initiatives in CMS’ Innovation Center, which I lead, are relevant to our work.

Recently, a Department of Health and Human Services (HHS) report showed that an estimated 50,000 fewer patients died in hospitals, 1.3 million fewer adverse events and infections occurred, and approximately $12 billion in healthcare costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013. This progress toward a safer healthcare system occurred during a period of concerted attention directed by hospitals and hospitalists throughout the country at reducing adverse events. These efforts were also due in part to provisions of the Affordable Care Act such as Medicare payment incentives to improve the quality of care and the HHS Partnership for Patients initiative. The Partnership for Patients is a nationwide public-private collaboration that began in April 2011 with two main goals: Reduce preventable hospital-acquired conditions by 40% and 30-day readmissions by 20%. Since the Partnership for Patients was launched, the vast majority of U.S. hospitals and many other stakeholders have joined the collaborative effort and delivered results.

CMS is committed to making even greater progress toward keeping people as safe and healthy as possible. That is why we have launched a second round of Hospital Engagement Network (HEN) contracts to continue reducing preventable hospital-acquired conditions and readmissions. HEN funding will be available to award contracts to national, regional, or state hospital associations, large healthcare organizations, or national affinity organizations that will support hospitals in their efforts to reduce preventable hospital-acquired conditions and readmissions. In February, CMS posted a request for proposals for HEN contracts to continue the success achieved in improving patient safety.

The Partnership for Patients and HENs are just one part of an overall effort by HHS to deliver better care, spend dollars more wisely, and improve health. Initiatives like the Partnership for Patients, accountable care organizations, quality improvement organizations, and others have helped reduce hospital readmissions in Medicare by nearly 8% between January 2012 and December 2013—translating into 150,000 fewer readmissions. Hospitalists have played a major role in these improvements.

On a broader front, CMS is taking action to improve healthcare so patients and their families can get the best care possible. To this end, CMS is focused on three key areas: (1) improving the way providers and hospitals are paid, (2) improving and innovating in care delivery, and (3) sharing information more broadly with providers and hospitals, consumers, and others to support better decisions.

When it comes to improving the way providers are paid, we want to reward value and care coordination—rather than volume and care duplication. We have over 25 payment and service delivery models at the CMS Innovation Center, but I will call out three that are particularly relevant to hospitalists. First, the ACO program is demonstrating positive results. Medicare has over 400 ACOs serving almost eight million beneficiaries. The Pioneer ACO program evaluation results demonstrated over $380 million in savings and improved quality—for example, improvement in 28 out of 33 quality measures, including patient experience of care. Based on these results, this model was the first from the CMS Innovation Center to be certified by the CMS actuary, and the Secretary of Health and Human Services announced her intent to expand the model components as a permanent part of the Medicare program through rulemaking. Second, in the Bundled Payments for Care Improvement model, we have thousands of providers (e.g. hospitals, physician groups) in phase 1 determining how they might improve care and considering taking on financial risk. The model includes acute and post-acute care, such as a 90-day episode for hip and knee replacement. We have 500 providers, and more that are willing to take on two-sided financial risk will likely be added in the next quarter. Hospitalists have a large role to play in improving quality and reducing costs in this model. Finally, the State Innovation Model is driving state and local change. In this model, we are funding and partnering with states on comprehensive delivery system reform. Seventeen states are implementing interventions, and 21 states and territories are designing their plans. The state is encouraged to partner with payers, providers, employers, public health entities, and others in the state to strive within the whole state population for better care, smarter spending, and healthier people. Many states are implementing payment models such as ACOs and bundled payments in Medicaid and with private payers. Increasingly, hospital medicine groups are going to value-based in the quality and efficiency of care delivery, both within the hospital walls and for episodes of care. This will entail stronger linkages and teamwork, both within the hospital and with clinicians in the community. It will also require a much stronger focus on predicting which patients are at risk of decompensation and delivering tailored interventions, including care management and technology to monitor patients in the home and other settings.

To improve care delivery, we are supporting providers to find new ways to coordinate and integrate care. For example, discharging a patient from the hospital without clear instructions on how to take care of themselves at home, when they should take their medicines, or when to check back in with the doctor can lead to an unnecessary readmission back into the hospital. This is especially true of individuals who have complex illnesses or diseases that may be more difficult to manage. We are supporting care improvement through a variety of channels, including facilitating hospitals and community groups teaming up to share best practices, and we applaud the Society of Hospital Medicine’s BOOST program, which is focused on peer mentoring and improvement.

Finally, as we look to improve the way information is distributed, we are working to create more transparency on the cost and quality of care, to bring electronic health information to inform care, and to bring the most recent scientific evidence to the point of care so we can bolster clinical decision making. Necessary information needs to be available to the treating physician and patients across settings. We must continue to improve the interoperability and usability of electronic health records so that they can enable improvement and care delivery.

I hope that as hospitalists you will take a closer look at the HHS initiatives I’ve described here—and others—and consider becoming a participant. Hospital medicine physicians are already leading many of these initiatives and are a positive force for health system transformation. As I look back on my last four-plus years at CMS (which sometimes feel like 30 years), I am amazed by how much progress we have made in improving the quality of care (e.g. over 95% of measures in CMS quality programs have improved over the last three years), spending dollars more wisely (e.g. lowest cost growth in the last four years in over 50 years), and improving the health of the nation (e.g. decreased smoking rates). Our nation is moving rapidly toward accountable, alternative payment models, including the recent legislation to “fix the SGR,” and I have seen hospitalists lead progress towards adopting these models nationally and locally. A challenge for all of us is to accelerate the pace of positive change and relentlessly pursue improved patient outcomes and a higher performing health system. But I know hospitalists are up to this challenge.

Thank you for all the work that you do every day on behalf of your patients and a better health system.

As a hospitalist myself, I have seen firsthand the need for a healthcare system that provides better care, spends dollars more wisely, and keeps people healthier. I practice on weekends taking care of children, many of whom have multiple chronic conditions and fragile social support, and their families. I love patient care; however, too many times, we hospitalists see patients whose fragmented care results in poor outcomes and repeated hospitalizations.

In my current role at the Centers for Medicare and Medicaid Services (CMS), I am pleased to see that Secretary Burwell is confronting these problems head on, with concrete goals for shifting the equation in how we pay for care. Specifically, we announced the goal of moving 30% of payments by 2016 into alternative payment models such as accountable care organizations (ACOs) or bundled payments, where the provider is accountable for total cost of care and quality. We set the goal of 50% of payments in these models by 2018. In 2011, Medicare had essentially zero payments in these models, but by 2014, we have reached 20% and growing in alternative payment models. Hospitalists can play a significant role in this healthcare transformation, and several initiatives in CMS’ Innovation Center, which I lead, are relevant to our work.

Recently, a Department of Health and Human Services (HHS) report showed that an estimated 50,000 fewer patients died in hospitals, 1.3 million fewer adverse events and infections occurred, and approximately $12 billion in healthcare costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013. This progress toward a safer healthcare system occurred during a period of concerted attention directed by hospitals and hospitalists throughout the country at reducing adverse events. These efforts were also due in part to provisions of the Affordable Care Act such as Medicare payment incentives to improve the quality of care and the HHS Partnership for Patients initiative. The Partnership for Patients is a nationwide public-private collaboration that began in April 2011 with two main goals: Reduce preventable hospital-acquired conditions by 40% and 30-day readmissions by 20%. Since the Partnership for Patients was launched, the vast majority of U.S. hospitals and many other stakeholders have joined the collaborative effort and delivered results.

CMS is committed to making even greater progress toward keeping people as safe and healthy as possible. That is why we have launched a second round of Hospital Engagement Network (HEN) contracts to continue reducing preventable hospital-acquired conditions and readmissions. HEN funding will be available to award contracts to national, regional, or state hospital associations, large healthcare organizations, or national affinity organizations that will support hospitals in their efforts to reduce preventable hospital-acquired conditions and readmissions. In February, CMS posted a request for proposals for HEN contracts to continue the success achieved in improving patient safety.

The Partnership for Patients and HENs are just one part of an overall effort by HHS to deliver better care, spend dollars more wisely, and improve health. Initiatives like the Partnership for Patients, accountable care organizations, quality improvement organizations, and others have helped reduce hospital readmissions in Medicare by nearly 8% between January 2012 and December 2013—translating into 150,000 fewer readmissions. Hospitalists have played a major role in these improvements.

On a broader front, CMS is taking action to improve healthcare so patients and their families can get the best care possible. To this end, CMS is focused on three key areas: (1) improving the way providers and hospitals are paid, (2) improving and innovating in care delivery, and (3) sharing information more broadly with providers and hospitals, consumers, and others to support better decisions.

When it comes to improving the way providers are paid, we want to reward value and care coordination—rather than volume and care duplication. We have over 25 payment and service delivery models at the CMS Innovation Center, but I will call out three that are particularly relevant to hospitalists. First, the ACO program is demonstrating positive results. Medicare has over 400 ACOs serving almost eight million beneficiaries. The Pioneer ACO program evaluation results demonstrated over $380 million in savings and improved quality—for example, improvement in 28 out of 33 quality measures, including patient experience of care. Based on these results, this model was the first from the CMS Innovation Center to be certified by the CMS actuary, and the Secretary of Health and Human Services announced her intent to expand the model components as a permanent part of the Medicare program through rulemaking. Second, in the Bundled Payments for Care Improvement model, we have thousands of providers (e.g. hospitals, physician groups) in phase 1 determining how they might improve care and considering taking on financial risk. The model includes acute and post-acute care, such as a 90-day episode for hip and knee replacement. We have 500 providers, and more that are willing to take on two-sided financial risk will likely be added in the next quarter. Hospitalists have a large role to play in improving quality and reducing costs in this model. Finally, the State Innovation Model is driving state and local change. In this model, we are funding and partnering with states on comprehensive delivery system reform. Seventeen states are implementing interventions, and 21 states and territories are designing their plans. The state is encouraged to partner with payers, providers, employers, public health entities, and others in the state to strive within the whole state population for better care, smarter spending, and healthier people. Many states are implementing payment models such as ACOs and bundled payments in Medicaid and with private payers. Increasingly, hospital medicine groups are going to value-based in the quality and efficiency of care delivery, both within the hospital walls and for episodes of care. This will entail stronger linkages and teamwork, both within the hospital and with clinicians in the community. It will also require a much stronger focus on predicting which patients are at risk of decompensation and delivering tailored interventions, including care management and technology to monitor patients in the home and other settings.

To improve care delivery, we are supporting providers to find new ways to coordinate and integrate care. For example, discharging a patient from the hospital without clear instructions on how to take care of themselves at home, when they should take their medicines, or when to check back in with the doctor can lead to an unnecessary readmission back into the hospital. This is especially true of individuals who have complex illnesses or diseases that may be more difficult to manage. We are supporting care improvement through a variety of channels, including facilitating hospitals and community groups teaming up to share best practices, and we applaud the Society of Hospital Medicine’s BOOST program, which is focused on peer mentoring and improvement.

Finally, as we look to improve the way information is distributed, we are working to create more transparency on the cost and quality of care, to bring electronic health information to inform care, and to bring the most recent scientific evidence to the point of care so we can bolster clinical decision making. Necessary information needs to be available to the treating physician and patients across settings. We must continue to improve the interoperability and usability of electronic health records so that they can enable improvement and care delivery.

I hope that as hospitalists you will take a closer look at the HHS initiatives I’ve described here—and others—and consider becoming a participant. Hospital medicine physicians are already leading many of these initiatives and are a positive force for health system transformation. As I look back on my last four-plus years at CMS (which sometimes feel like 30 years), I am amazed by how much progress we have made in improving the quality of care (e.g. over 95% of measures in CMS quality programs have improved over the last three years), spending dollars more wisely (e.g. lowest cost growth in the last four years in over 50 years), and improving the health of the nation (e.g. decreased smoking rates). Our nation is moving rapidly toward accountable, alternative payment models, including the recent legislation to “fix the SGR,” and I have seen hospitalists lead progress towards adopting these models nationally and locally. A challenge for all of us is to accelerate the pace of positive change and relentlessly pursue improved patient outcomes and a higher performing health system. But I know hospitalists are up to this challenge.

Thank you for all the work that you do every day on behalf of your patients and a better health system.

As a hospitalist myself, I have seen firsthand the need for a healthcare system that provides better care, spends dollars more wisely, and keeps people healthier. I practice on weekends taking care of children, many of whom have multiple chronic conditions and fragile social support, and their families. I love patient care; however, too many times, we hospitalists see patients whose fragmented care results in poor outcomes and repeated hospitalizations.

In my current role at the Centers for Medicare and Medicaid Services (CMS), I am pleased to see that Secretary Burwell is confronting these problems head on, with concrete goals for shifting the equation in how we pay for care. Specifically, we announced the goal of moving 30% of payments by 2016 into alternative payment models such as accountable care organizations (ACOs) or bundled payments, where the provider is accountable for total cost of care and quality. We set the goal of 50% of payments in these models by 2018. In 2011, Medicare had essentially zero payments in these models, but by 2014, we have reached 20% and growing in alternative payment models. Hospitalists can play a significant role in this healthcare transformation, and several initiatives in CMS’ Innovation Center, which I lead, are relevant to our work.

Recently, a Department of Health and Human Services (HHS) report showed that an estimated 50,000 fewer patients died in hospitals, 1.3 million fewer adverse events and infections occurred, and approximately $12 billion in healthcare costs were saved as a result of a reduction in hospital-acquired conditions from 2010 to 2013. This progress toward a safer healthcare system occurred during a period of concerted attention directed by hospitals and hospitalists throughout the country at reducing adverse events. These efforts were also due in part to provisions of the Affordable Care Act such as Medicare payment incentives to improve the quality of care and the HHS Partnership for Patients initiative. The Partnership for Patients is a nationwide public-private collaboration that began in April 2011 with two main goals: Reduce preventable hospital-acquired conditions by 40% and 30-day readmissions by 20%. Since the Partnership for Patients was launched, the vast majority of U.S. hospitals and many other stakeholders have joined the collaborative effort and delivered results.

CMS is committed to making even greater progress toward keeping people as safe and healthy as possible. That is why we have launched a second round of Hospital Engagement Network (HEN) contracts to continue reducing preventable hospital-acquired conditions and readmissions. HEN funding will be available to award contracts to national, regional, or state hospital associations, large healthcare organizations, or national affinity organizations that will support hospitals in their efforts to reduce preventable hospital-acquired conditions and readmissions. In February, CMS posted a request for proposals for HEN contracts to continue the success achieved in improving patient safety.

The Partnership for Patients and HENs are just one part of an overall effort by HHS to deliver better care, spend dollars more wisely, and improve health. Initiatives like the Partnership for Patients, accountable care organizations, quality improvement organizations, and others have helped reduce hospital readmissions in Medicare by nearly 8% between January 2012 and December 2013—translating into 150,000 fewer readmissions. Hospitalists have played a major role in these improvements.

On a broader front, CMS is taking action to improve healthcare so patients and their families can get the best care possible. To this end, CMS is focused on three key areas: (1) improving the way providers and hospitals are paid, (2) improving and innovating in care delivery, and (3) sharing information more broadly with providers and hospitals, consumers, and others to support better decisions.

When it comes to improving the way providers are paid, we want to reward value and care coordination—rather than volume and care duplication. We have over 25 payment and service delivery models at the CMS Innovation Center, but I will call out three that are particularly relevant to hospitalists. First, the ACO program is demonstrating positive results. Medicare has over 400 ACOs serving almost eight million beneficiaries. The Pioneer ACO program evaluation results demonstrated over $380 million in savings and improved quality—for example, improvement in 28 out of 33 quality measures, including patient experience of care. Based on these results, this model was the first from the CMS Innovation Center to be certified by the CMS actuary, and the Secretary of Health and Human Services announced her intent to expand the model components as a permanent part of the Medicare program through rulemaking. Second, in the Bundled Payments for Care Improvement model, we have thousands of providers (e.g. hospitals, physician groups) in phase 1 determining how they might improve care and considering taking on financial risk. The model includes acute and post-acute care, such as a 90-day episode for hip and knee replacement. We have 500 providers, and more that are willing to take on two-sided financial risk will likely be added in the next quarter. Hospitalists have a large role to play in improving quality and reducing costs in this model. Finally, the State Innovation Model is driving state and local change. In this model, we are funding and partnering with states on comprehensive delivery system reform. Seventeen states are implementing interventions, and 21 states and territories are designing their plans. The state is encouraged to partner with payers, providers, employers, public health entities, and others in the state to strive within the whole state population for better care, smarter spending, and healthier people. Many states are implementing payment models such as ACOs and bundled payments in Medicaid and with private payers. Increasingly, hospital medicine groups are going to value-based in the quality and efficiency of care delivery, both within the hospital walls and for episodes of care. This will entail stronger linkages and teamwork, both within the hospital and with clinicians in the community. It will also require a much stronger focus on predicting which patients are at risk of decompensation and delivering tailored interventions, including care management and technology to monitor patients in the home and other settings.

To improve care delivery, we are supporting providers to find new ways to coordinate and integrate care. For example, discharging a patient from the hospital without clear instructions on how to take care of themselves at home, when they should take their medicines, or when to check back in with the doctor can lead to an unnecessary readmission back into the hospital. This is especially true of individuals who have complex illnesses or diseases that may be more difficult to manage. We are supporting care improvement through a variety of channels, including facilitating hospitals and community groups teaming up to share best practices, and we applaud the Society of Hospital Medicine’s BOOST program, which is focused on peer mentoring and improvement.

Finally, as we look to improve the way information is distributed, we are working to create more transparency on the cost and quality of care, to bring electronic health information to inform care, and to bring the most recent scientific evidence to the point of care so we can bolster clinical decision making. Necessary information needs to be available to the treating physician and patients across settings. We must continue to improve the interoperability and usability of electronic health records so that they can enable improvement and care delivery.

I hope that as hospitalists you will take a closer look at the HHS initiatives I’ve described here—and others—and consider becoming a participant. Hospital medicine physicians are already leading many of these initiatives and are a positive force for health system transformation. As I look back on my last four-plus years at CMS (which sometimes feel like 30 years), I am amazed by how much progress we have made in improving the quality of care (e.g. over 95% of measures in CMS quality programs have improved over the last three years), spending dollars more wisely (e.g. lowest cost growth in the last four years in over 50 years), and improving the health of the nation (e.g. decreased smoking rates). Our nation is moving rapidly toward accountable, alternative payment models, including the recent legislation to “fix the SGR,” and I have seen hospitalists lead progress towards adopting these models nationally and locally. A challenge for all of us is to accelerate the pace of positive change and relentlessly pursue improved patient outcomes and a higher performing health system. But I know hospitalists are up to this challenge.

Thank you for all the work that you do every day on behalf of your patients and a better health system.

The largest drivers of healthcare costs are physicians, but these professionals are among the least comfortable discussing healthcare value. According to Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at NYU Langone Medical Center in New York City, physicians prefer to focus on individual patient interactions rather than questions of cost and population management.

Choosing Wisely, a campaign launched in April 2012 by the American Board of Internal Medicine Foundation to encourage conversations between providers and patients, is designed to help patients choose tests, procedures, and care that are necessary, evidence-based, and not harmful or redundant, while allowing physicians to approach the question of value in terms of how to best care for each patient.¹ By focusing on very common practices and relying on well-established evidence as the basis of each specialty’s recommendations, Choosing Wisely has garnered widespread support.

Below are five examples of Choosing Wisely programs, initiated by hospitalists around the country. Each is doable, scalable, and reproducible in a variety of inpatient settings.

Mount Sinai Hospital, New York City

“Lose the Tube” was initiated at New York’s Mount Sinai Medical Center to reduce the incidences of catheter-associated urinary tract infection, or CAUTI. The five-month intervention period began April 1, 2014, and lasted through August 31, 2014.

Using electronic health records (EHRs), urinary catheter patients were identified based on nursing documentation and urinary catheter (UC) orders. Once patients were “flagged,” hospitalists would approach each of their providers during interdisciplinary rounds and ask if the patient needed the Foley. Additionally, unit-based metrics of UC and CAUTI were disseminated at weekly meetings to unit medical directors to promote engagement, discussion, and transparency; educational reminders were given monthly in orientations to subinterns, residents, and attending physicians.

“Lose the Tube” proved very successful, reducing rates to 0.2 CAUTI/month from 2.67 CAUTI/month during the intervention period. Total catheter days decreased to 4,318 from 5,610, to 877.0 catheter days/month from 948.5 catheter days/month. CAUTI rate was decreased from to 0.23 CAUTI/1000 catheter days from 2.85 CAUTI/1000 catheter days.

The simplicity of the approach of “Lose the Tube” makes it easily reproducible in other institutions. The intervention uses the existing EHR to readily identify UC in patients; the interaction between the hospitalist and other clinicians is succinct and easily integrated into existing communications. As Hyung Cho, MD, director of quality and patient safety at Mount Sinai, says, “Awareness for Choosing Wisely is definitely there. We just need to figure out ways to integrate these recommendations into our systems.”²

Cincinnati Children’s Hospital Medical Center

The Cincinnati Children’s Hospital initiated a campaign to reduce continuous pulse oximetry use for patients with asthma and bronchiolitis in line with Choosing Wisely recommendations and the hospital’s own guidelines. The objective was to reduce continuous pulse oximetry time after weaning to room air or weaning to every two-hour albuterol treatments from 10.7 hours (baseline) by at least 50% to 5.4 hours.

The initial step was to define goals for discontinuation of pulse oximetry of greater than 90% oxygen saturation on room air or weaning to albuterol treatments every two hours based on existing weaning protocol. These goals were communicated to the unit staff at monthly resident team and nursing meetings. At this point, a decrease was seen in the median time per week to 4.1 hours.

The next intervention changed default settings in the bronchiolitis electronic order set, which allowed the nurse to transition to intermittent pulse oximetry when goals were met and no new clinical concerns arose. A three-item checklist was introduced to identify patients whose goals were met for timely discontinuation during the previous shift, which resulted in a further reduction of more than 70% from baseline, to a median time per week of 3.1 hours.

The straightforward simplicity of interventions, including a paper checklist and changes to order sets, makes them reproducible in a variety of other hospital settings. Another key facilitator was the involvement of the nursing staff. Educating nurses on local guidelines for intermittent oximetry use empowered them to proactively transition patients who met the goals and presented no clinical concerns, which removed the step of calling the resident to change the order.³

Stanford University Hospital

Lisa Shieh, MD, PhD, reports that Stanford began by creating a steering committee of representatives from all hospital departments, which resulted in the development of evidence-based guidelines for necessary transfusions. The hospital’s EHR was programmed to fire a best practice alert (BPA) should a physician order a transfusion in a hemodynamically stable (hemoglobin reading 7 or above) patient; however, the smart BPA did not fire for patients diagnosed with bleeding disorders, hematology and oncology patients, and other special populations. Should a physician choose to transfuse despite the BPA, a reason had to be entered into the EHR.

Prior to the intervention, 50% of transfusions at Stanford were given to patients with a hemoglobin reading of 8 or above. After the intervention, only 30% fell into that category.

“Giving physicians information via the BPA in the moment they are treating the patient really made the difference,” Dr. Shieh says. “The fact that it allows them to explain why they are choosing to transfuse a particular patient allows us to understand appropriate blood usage better.”

“There are patients who really do need blood but exist outside the guidelines.”

“Adding the educational component really helped make the change in how physicians practice. When they understand why they are being asked to do things differently, they are more likely to change their behavior.” —Manya Gupta, MD

University of California, San Diego

Remus Popa, MD, and Gregory Seymann, MD, SFHM, instituted a program at the University of California at San Diego hospital to reduce the number of patients in a telemetry bed who receive no benefit from cardiac monitoring. When physicians entered telemetry orders into a patient’s EHR, they were prompted to choose a diagnosis from the list of accepted indications programmed into the system. They were also able to choose a diagnosis of “Other” for patients who existed outside the guidelines and then explain their reasoning for ordering cardiac monitoring.

“This system is not attempting to limit the physician’s autonomy,” Dr. Popa explains. “Choosing ‘Other’ allows the clinician to order telemetry for patients with special situations, maybe not entirely addressed by the guidelines, and entering a reason can help tweak the telemetry order set going forward.”

The intervention successfully reduced the use of telemetry to a post-intervention rate of 20% from a baseline of 44%. An additional benefit was the 1.2-hour reduction in time elapsed from presentation at the ED to being placed in the telemetry bed. Because fewer of these beds were in use at any time, patients who could benefit from cardiac monitoring were in place faster.

Rush University Hospital, Chicago

Hospitalist Manya Gupta, MD, an assistant professor in the department of internal medicine, and her team at Rush embarked on a program to decrease the number of blood transfusions performed per year to be more in line with new data demonstrating that more restrictive transfusions result in better patient outcomes. The hospital had originally tried to reduce the number of transfusions by amending the blood transfusion order set in the EHR system, requiring physicians to select the indication for the transfusion from a checklist. If the desired indication was not found on the checklist, they could check “Other” and proceed with the transfusion, even if the patient did not require a transfusion. This system did not result in a meaningful decrease in transfusion.

“Accordingly, reducing these inefficiencies and improving coordination across the care continuum are top priorities within healthcare delivery

organizations. Maximize effective, efficient care and eliminate the waste.” —Andrew Masica, MD, MSCI

In March 2013, Rush implemented a two-pronged approach to changing its transfusion culture. The indication of “Other” in the Epic EHR system was removed, and all indications on the checklist were made more specific. Acceptable choices included “hemoglobin <7” or “hemoglobin <8 with symptoms” or “active ischemic or cardiac event.” This change in the order sets also allowed Rush to more precisely track why patients were receiving blood—useful information to build on going forward.

Concurrently, the hospital initiated an intense educational campaign as part of its safety conferences, regularly scheduled meetings for house staff and hospitalists, in which the staff were taught the appropriate indications for blood transfusion and what data exist in the literature to support limiting transfusions, as well as how to transfuse correctly.

Dr. Gupta stresses that educating the physicians made a major impact on the program’s success. “Adding the educational component really helped make the change in how physicians practice,” she says. “When they understand why they are being asked to do things differently, they are more likely to change their behavior.”

Rush successfully lowered the total number of transfusions from 1,491 in the 14 months prior to the intervention to 953 transfusions between May 2013 and June 2014, a decrease of 36%. Transfusions in patients with hemoglobin greater than 8 were tracked during the same time periods, and that amount dropped to 121 post-intervention from 320 pre-intervention, a reduction of over 60%.

Dr. Gupta says that the latter reduction was particularly satisfying, because “not only were we able to reduce the total amount of blood transfused but also to keep the blood that was transfused within the guidelines.”

In Sum

Choosing Wisely addresses the complex relationship between cost and quality in healthcare.

“Fragmented, wasteful systems, particularly where there is duplication of services, produce poor outcomes at higher costs,” says Andrew Masica, MD, MSCI, vice president and chief clinical effectiveness officer at Baylor Scott and White Healthcare of Dallas. “Accordingly, reducing these inefficiencies and improving coordination across the care continuum are top priorities within healthcare delivery organizations. Maximize effective, efficient care and eliminate the waste.”

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

Residents Choosing Wisely

Drs. Popa and Seymann were inspired by their Choosing Wisely project success to actively involve the residents at UCSD in improving healthcare value at their hospital.

Every two weeks, Dr. Popa and Dr. Seymann introduce a new group of students to one or more wasteful healthcare practices, often drawing them from Choosing Wisely recommendations.

“These discussions are eye-opening moments for the students, when they suddenly see there are high-cost practices which really don’t benefit patients,” Dr. Seymann says.

The instructors point the residents toward data from their hospital or literature on the topic and instruct them to educate themselves with this material and return with proposals to decrease the wasteful practices.

“The residents are the front-line workers, doing the day-to-day work on the units,” Dr. Seymann says. “They know what works and what needs fixing.”

Many of their suggestions are creative and practical and have made major contributions to more efficient, less wasteful red blood cell and daily lab protocols, as well as telemetry usage.

References

1. American Board of Internal Medicine. About Choosing Wisely. ABIM website. Accessed June 9, 2015.
2. Cho H, Khalil S, Wallach F, et al. Lose the tube: preventing catheter-associated urinary tract infections. Meeting abstract. Accessed June 9, 2015.
3. Schondelmeyer AC, Simmons JM, Statile AM, et al. Using quality improvement to reduce continuous pulse oximetry use in children with wheezing. Pediatrics. 2015;135(4):e1044-e1051.

The largest drivers of healthcare costs are physicians, but these professionals are among the least comfortable discussing healthcare value. According to Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at NYU Langone Medical Center in New York City, physicians prefer to focus on individual patient interactions rather than questions of cost and population management.

Choosing Wisely, a campaign launched in April 2012 by the American Board of Internal Medicine Foundation to encourage conversations between providers and patients, is designed to help patients choose tests, procedures, and care that are necessary, evidence-based, and not harmful or redundant, while allowing physicians to approach the question of value in terms of how to best care for each patient.¹ By focusing on very common practices and relying on well-established evidence as the basis of each specialty’s recommendations, Choosing Wisely has garnered widespread support.

Below are five examples of Choosing Wisely programs, initiated by hospitalists around the country. Each is doable, scalable, and reproducible in a variety of inpatient settings.

Mount Sinai Hospital, New York City

“Lose the Tube” was initiated at New York’s Mount Sinai Medical Center to reduce the incidences of catheter-associated urinary tract infection, or CAUTI. The five-month intervention period began April 1, 2014, and lasted through August 31, 2014.

Using electronic health records (EHRs), urinary catheter patients were identified based on nursing documentation and urinary catheter (UC) orders. Once patients were “flagged,” hospitalists would approach each of their providers during interdisciplinary rounds and ask if the patient needed the Foley. Additionally, unit-based metrics of UC and CAUTI were disseminated at weekly meetings to unit medical directors to promote engagement, discussion, and transparency; educational reminders were given monthly in orientations to subinterns, residents, and attending physicians.

“Lose the Tube” proved very successful, reducing rates to 0.2 CAUTI/month from 2.67 CAUTI/month during the intervention period. Total catheter days decreased to 4,318 from 5,610, to 877.0 catheter days/month from 948.5 catheter days/month. CAUTI rate was decreased from to 0.23 CAUTI/1000 catheter days from 2.85 CAUTI/1000 catheter days.

The simplicity of the approach of “Lose the Tube” makes it easily reproducible in other institutions. The intervention uses the existing EHR to readily identify UC in patients; the interaction between the hospitalist and other clinicians is succinct and easily integrated into existing communications. As Hyung Cho, MD, director of quality and patient safety at Mount Sinai, says, “Awareness for Choosing Wisely is definitely there. We just need to figure out ways to integrate these recommendations into our systems.”²

Cincinnati Children’s Hospital Medical Center

The Cincinnati Children’s Hospital initiated a campaign to reduce continuous pulse oximetry use for patients with asthma and bronchiolitis in line with Choosing Wisely recommendations and the hospital’s own guidelines. The objective was to reduce continuous pulse oximetry time after weaning to room air or weaning to every two-hour albuterol treatments from 10.7 hours (baseline) by at least 50% to 5.4 hours.

The initial step was to define goals for discontinuation of pulse oximetry of greater than 90% oxygen saturation on room air or weaning to albuterol treatments every two hours based on existing weaning protocol. These goals were communicated to the unit staff at monthly resident team and nursing meetings. At this point, a decrease was seen in the median time per week to 4.1 hours.

The next intervention changed default settings in the bronchiolitis electronic order set, which allowed the nurse to transition to intermittent pulse oximetry when goals were met and no new clinical concerns arose. A three-item checklist was introduced to identify patients whose goals were met for timely discontinuation during the previous shift, which resulted in a further reduction of more than 70% from baseline, to a median time per week of 3.1 hours.

The straightforward simplicity of interventions, including a paper checklist and changes to order sets, makes them reproducible in a variety of other hospital settings. Another key facilitator was the involvement of the nursing staff. Educating nurses on local guidelines for intermittent oximetry use empowered them to proactively transition patients who met the goals and presented no clinical concerns, which removed the step of calling the resident to change the order.³

Stanford University Hospital

Lisa Shieh, MD, PhD, reports that Stanford began by creating a steering committee of representatives from all hospital departments, which resulted in the development of evidence-based guidelines for necessary transfusions. The hospital’s EHR was programmed to fire a best practice alert (BPA) should a physician order a transfusion in a hemodynamically stable (hemoglobin reading 7 or above) patient; however, the smart BPA did not fire for patients diagnosed with bleeding disorders, hematology and oncology patients, and other special populations. Should a physician choose to transfuse despite the BPA, a reason had to be entered into the EHR.

Prior to the intervention, 50% of transfusions at Stanford were given to patients with a hemoglobin reading of 8 or above. After the intervention, only 30% fell into that category.

“Giving physicians information via the BPA in the moment they are treating the patient really made the difference,” Dr. Shieh says. “The fact that it allows them to explain why they are choosing to transfuse a particular patient allows us to understand appropriate blood usage better.”

“There are patients who really do need blood but exist outside the guidelines.”

“Adding the educational component really helped make the change in how physicians practice. When they understand why they are being asked to do things differently, they are more likely to change their behavior.” —Manya Gupta, MD

University of California, San Diego

Remus Popa, MD, and Gregory Seymann, MD, SFHM, instituted a program at the University of California at San Diego hospital to reduce the number of patients in a telemetry bed who receive no benefit from cardiac monitoring. When physicians entered telemetry orders into a patient’s EHR, they were prompted to choose a diagnosis from the list of accepted indications programmed into the system. They were also able to choose a diagnosis of “Other” for patients who existed outside the guidelines and then explain their reasoning for ordering cardiac monitoring.

“This system is not attempting to limit the physician’s autonomy,” Dr. Popa explains. “Choosing ‘Other’ allows the clinician to order telemetry for patients with special situations, maybe not entirely addressed by the guidelines, and entering a reason can help tweak the telemetry order set going forward.”

The intervention successfully reduced the use of telemetry to a post-intervention rate of 20% from a baseline of 44%. An additional benefit was the 1.2-hour reduction in time elapsed from presentation at the ED to being placed in the telemetry bed. Because fewer of these beds were in use at any time, patients who could benefit from cardiac monitoring were in place faster.

Rush University Hospital, Chicago

Hospitalist Manya Gupta, MD, an assistant professor in the department of internal medicine, and her team at Rush embarked on a program to decrease the number of blood transfusions performed per year to be more in line with new data demonstrating that more restrictive transfusions result in better patient outcomes. The hospital had originally tried to reduce the number of transfusions by amending the blood transfusion order set in the EHR system, requiring physicians to select the indication for the transfusion from a checklist. If the desired indication was not found on the checklist, they could check “Other” and proceed with the transfusion, even if the patient did not require a transfusion. This system did not result in a meaningful decrease in transfusion.

“Accordingly, reducing these inefficiencies and improving coordination across the care continuum are top priorities within healthcare delivery

organizations. Maximize effective, efficient care and eliminate the waste.” —Andrew Masica, MD, MSCI

In March 2013, Rush implemented a two-pronged approach to changing its transfusion culture. The indication of “Other” in the Epic EHR system was removed, and all indications on the checklist were made more specific. Acceptable choices included “hemoglobin <7” or “hemoglobin <8 with symptoms” or “active ischemic or cardiac event.” This change in the order sets also allowed Rush to more precisely track why patients were receiving blood—useful information to build on going forward.

Concurrently, the hospital initiated an intense educational campaign as part of its safety conferences, regularly scheduled meetings for house staff and hospitalists, in which the staff were taught the appropriate indications for blood transfusion and what data exist in the literature to support limiting transfusions, as well as how to transfuse correctly.

Dr. Gupta stresses that educating the physicians made a major impact on the program’s success. “Adding the educational component really helped make the change in how physicians practice,” she says. “When they understand why they are being asked to do things differently, they are more likely to change their behavior.”

Rush successfully lowered the total number of transfusions from 1,491 in the 14 months prior to the intervention to 953 transfusions between May 2013 and June 2014, a decrease of 36%. Transfusions in patients with hemoglobin greater than 8 were tracked during the same time periods, and that amount dropped to 121 post-intervention from 320 pre-intervention, a reduction of over 60%.

Dr. Gupta says that the latter reduction was particularly satisfying, because “not only were we able to reduce the total amount of blood transfused but also to keep the blood that was transfused within the guidelines.”

In Sum

Choosing Wisely addresses the complex relationship between cost and quality in healthcare.

“Fragmented, wasteful systems, particularly where there is duplication of services, produce poor outcomes at higher costs,” says Andrew Masica, MD, MSCI, vice president and chief clinical effectiveness officer at Baylor Scott and White Healthcare of Dallas. “Accordingly, reducing these inefficiencies and improving coordination across the care continuum are top priorities within healthcare delivery organizations. Maximize effective, efficient care and eliminate the waste.”

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

Residents Choosing Wisely

Drs. Popa and Seymann were inspired by their Choosing Wisely project success to actively involve the residents at UCSD in improving healthcare value at their hospital.

Every two weeks, Dr. Popa and Dr. Seymann introduce a new group of students to one or more wasteful healthcare practices, often drawing them from Choosing Wisely recommendations.

“These discussions are eye-opening moments for the students, when they suddenly see there are high-cost practices which really don’t benefit patients,” Dr. Seymann says.

The instructors point the residents toward data from their hospital or literature on the topic and instruct them to educate themselves with this material and return with proposals to decrease the wasteful practices.

“The residents are the front-line workers, doing the day-to-day work on the units,” Dr. Seymann says. “They know what works and what needs fixing.”

Many of their suggestions are creative and practical and have made major contributions to more efficient, less wasteful red blood cell and daily lab protocols, as well as telemetry usage.

References

1. American Board of Internal Medicine. About Choosing Wisely. ABIM website. Accessed June 9, 2015.
2. Cho H, Khalil S, Wallach F, et al. Lose the tube: preventing catheter-associated urinary tract infections. Meeting abstract. Accessed June 9, 2015.
3. Schondelmeyer AC, Simmons JM, Statile AM, et al. Using quality improvement to reduce continuous pulse oximetry use in children with wheezing. Pediatrics. 2015;135(4):e1044-e1051.

The largest drivers of healthcare costs are physicians, but these professionals are among the least comfortable discussing healthcare value. According to Leora Horwitz, MD, MHS, director of the Center for Healthcare Innovation and Delivery Science at NYU Langone Medical Center in New York City, physicians prefer to focus on individual patient interactions rather than questions of cost and population management.

Choosing Wisely, a campaign launched in April 2012 by the American Board of Internal Medicine Foundation to encourage conversations between providers and patients, is designed to help patients choose tests, procedures, and care that are necessary, evidence-based, and not harmful or redundant, while allowing physicians to approach the question of value in terms of how to best care for each patient.¹ By focusing on very common practices and relying on well-established evidence as the basis of each specialty’s recommendations, Choosing Wisely has garnered widespread support.

Below are five examples of Choosing Wisely programs, initiated by hospitalists around the country. Each is doable, scalable, and reproducible in a variety of inpatient settings.

Mount Sinai Hospital, New York City

“Lose the Tube” was initiated at New York’s Mount Sinai Medical Center to reduce the incidences of catheter-associated urinary tract infection, or CAUTI. The five-month intervention period began April 1, 2014, and lasted through August 31, 2014.

Using electronic health records (EHRs), urinary catheter patients were identified based on nursing documentation and urinary catheter (UC) orders. Once patients were “flagged,” hospitalists would approach each of their providers during interdisciplinary rounds and ask if the patient needed the Foley. Additionally, unit-based metrics of UC and CAUTI were disseminated at weekly meetings to unit medical directors to promote engagement, discussion, and transparency; educational reminders were given monthly in orientations to subinterns, residents, and attending physicians.

“Lose the Tube” proved very successful, reducing rates to 0.2 CAUTI/month from 2.67 CAUTI/month during the intervention period. Total catheter days decreased to 4,318 from 5,610, to 877.0 catheter days/month from 948.5 catheter days/month. CAUTI rate was decreased from to 0.23 CAUTI/1000 catheter days from 2.85 CAUTI/1000 catheter days.

The simplicity of the approach of “Lose the Tube” makes it easily reproducible in other institutions. The intervention uses the existing EHR to readily identify UC in patients; the interaction between the hospitalist and other clinicians is succinct and easily integrated into existing communications. As Hyung Cho, MD, director of quality and patient safety at Mount Sinai, says, “Awareness for Choosing Wisely is definitely there. We just need to figure out ways to integrate these recommendations into our systems.”²

Cincinnati Children’s Hospital Medical Center

The Cincinnati Children’s Hospital initiated a campaign to reduce continuous pulse oximetry use for patients with asthma and bronchiolitis in line with Choosing Wisely recommendations and the hospital’s own guidelines. The objective was to reduce continuous pulse oximetry time after weaning to room air or weaning to every two-hour albuterol treatments from 10.7 hours (baseline) by at least 50% to 5.4 hours.

The initial step was to define goals for discontinuation of pulse oximetry of greater than 90% oxygen saturation on room air or weaning to albuterol treatments every two hours based on existing weaning protocol. These goals were communicated to the unit staff at monthly resident team and nursing meetings. At this point, a decrease was seen in the median time per week to 4.1 hours.

The next intervention changed default settings in the bronchiolitis electronic order set, which allowed the nurse to transition to intermittent pulse oximetry when goals were met and no new clinical concerns arose. A three-item checklist was introduced to identify patients whose goals were met for timely discontinuation during the previous shift, which resulted in a further reduction of more than 70% from baseline, to a median time per week of 3.1 hours.

The straightforward simplicity of interventions, including a paper checklist and changes to order sets, makes them reproducible in a variety of other hospital settings. Another key facilitator was the involvement of the nursing staff. Educating nurses on local guidelines for intermittent oximetry use empowered them to proactively transition patients who met the goals and presented no clinical concerns, which removed the step of calling the resident to change the order.³

Stanford University Hospital

Lisa Shieh, MD, PhD, reports that Stanford began by creating a steering committee of representatives from all hospital departments, which resulted in the development of evidence-based guidelines for necessary transfusions. The hospital’s EHR was programmed to fire a best practice alert (BPA) should a physician order a transfusion in a hemodynamically stable (hemoglobin reading 7 or above) patient; however, the smart BPA did not fire for patients diagnosed with bleeding disorders, hematology and oncology patients, and other special populations. Should a physician choose to transfuse despite the BPA, a reason had to be entered into the EHR.

Prior to the intervention, 50% of transfusions at Stanford were given to patients with a hemoglobin reading of 8 or above. After the intervention, only 30% fell into that category.

“Giving physicians information via the BPA in the moment they are treating the patient really made the difference,” Dr. Shieh says. “The fact that it allows them to explain why they are choosing to transfuse a particular patient allows us to understand appropriate blood usage better.”

“There are patients who really do need blood but exist outside the guidelines.”

“Adding the educational component really helped make the change in how physicians practice. When they understand why they are being asked to do things differently, they are more likely to change their behavior.” —Manya Gupta, MD

University of California, San Diego

Remus Popa, MD, and Gregory Seymann, MD, SFHM, instituted a program at the University of California at San Diego hospital to reduce the number of patients in a telemetry bed who receive no benefit from cardiac monitoring. When physicians entered telemetry orders into a patient’s EHR, they were prompted to choose a diagnosis from the list of accepted indications programmed into the system. They were also able to choose a diagnosis of “Other” for patients who existed outside the guidelines and then explain their reasoning for ordering cardiac monitoring.

“This system is not attempting to limit the physician’s autonomy,” Dr. Popa explains. “Choosing ‘Other’ allows the clinician to order telemetry for patients with special situations, maybe not entirely addressed by the guidelines, and entering a reason can help tweak the telemetry order set going forward.”

The intervention successfully reduced the use of telemetry to a post-intervention rate of 20% from a baseline of 44%. An additional benefit was the 1.2-hour reduction in time elapsed from presentation at the ED to being placed in the telemetry bed. Because fewer of these beds were in use at any time, patients who could benefit from cardiac monitoring were in place faster.

Rush University Hospital, Chicago

Hospitalist Manya Gupta, MD, an assistant professor in the department of internal medicine, and her team at Rush embarked on a program to decrease the number of blood transfusions performed per year to be more in line with new data demonstrating that more restrictive transfusions result in better patient outcomes. The hospital had originally tried to reduce the number of transfusions by amending the blood transfusion order set in the EHR system, requiring physicians to select the indication for the transfusion from a checklist. If the desired indication was not found on the checklist, they could check “Other” and proceed with the transfusion, even if the patient did not require a transfusion. This system did not result in a meaningful decrease in transfusion.

“Accordingly, reducing these inefficiencies and improving coordination across the care continuum are top priorities within healthcare delivery

organizations. Maximize effective, efficient care and eliminate the waste.” —Andrew Masica, MD, MSCI

In March 2013, Rush implemented a two-pronged approach to changing its transfusion culture. The indication of “Other” in the Epic EHR system was removed, and all indications on the checklist were made more specific. Acceptable choices included “hemoglobin <7” or “hemoglobin <8 with symptoms” or “active ischemic or cardiac event.” This change in the order sets also allowed Rush to more precisely track why patients were receiving blood—useful information to build on going forward.

Concurrently, the hospital initiated an intense educational campaign as part of its safety conferences, regularly scheduled meetings for house staff and hospitalists, in which the staff were taught the appropriate indications for blood transfusion and what data exist in the literature to support limiting transfusions, as well as how to transfuse correctly.

Dr. Gupta stresses that educating the physicians made a major impact on the program’s success. “Adding the educational component really helped make the change in how physicians practice,” she says. “When they understand why they are being asked to do things differently, they are more likely to change their behavior.”

Rush successfully lowered the total number of transfusions from 1,491 in the 14 months prior to the intervention to 953 transfusions between May 2013 and June 2014, a decrease of 36%. Transfusions in patients with hemoglobin greater than 8 were tracked during the same time periods, and that amount dropped to 121 post-intervention from 320 pre-intervention, a reduction of over 60%.

Dr. Gupta says that the latter reduction was particularly satisfying, because “not only were we able to reduce the total amount of blood transfused but also to keep the blood that was transfused within the guidelines.”

In Sum

Choosing Wisely addresses the complex relationship between cost and quality in healthcare.

“Fragmented, wasteful systems, particularly where there is duplication of services, produce poor outcomes at higher costs,” says Andrew Masica, MD, MSCI, vice president and chief clinical effectiveness officer at Baylor Scott and White Healthcare of Dallas. “Accordingly, reducing these inefficiencies and improving coordination across the care continuum are top priorities within healthcare delivery organizations. Maximize effective, efficient care and eliminate the waste.”

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

Residents Choosing Wisely

Drs. Popa and Seymann were inspired by their Choosing Wisely project success to actively involve the residents at UCSD in improving healthcare value at their hospital.

Every two weeks, Dr. Popa and Dr. Seymann introduce a new group of students to one or more wasteful healthcare practices, often drawing them from Choosing Wisely recommendations.

“These discussions are eye-opening moments for the students, when they suddenly see there are high-cost practices which really don’t benefit patients,” Dr. Seymann says.

The instructors point the residents toward data from their hospital or literature on the topic and instruct them to educate themselves with this material and return with proposals to decrease the wasteful practices.

“The residents are the front-line workers, doing the day-to-day work on the units,” Dr. Seymann says. “They know what works and what needs fixing.”

Many of their suggestions are creative and practical and have made major contributions to more efficient, less wasteful red blood cell and daily lab protocols, as well as telemetry usage.

References

1. American Board of Internal Medicine. About Choosing Wisely. ABIM website. Accessed June 9, 2015.
2. Cho H, Khalil S, Wallach F, et al. Lose the tube: preventing catheter-associated urinary tract infections. Meeting abstract. Accessed June 9, 2015.
3. Schondelmeyer AC, Simmons JM, Statile AM, et al. Using quality improvement to reduce continuous pulse oximetry use in children with wheezing. Pediatrics. 2015;135(4):e1044-e1051.

Securing institutional support is the first step in any Choosing Wisely project. Evaluate your hospital in the areas covered by Choosing Wisely recommendations. How does the number of transfusions occurring in your hospital compare to national averages? What about number of catheter days and frequency of CAUTIs?

Once you choose an area for improvement, present a strong business case, strongly supported by data and the best projections you can muster, to your hospital’s stakeholders to prove that your proposed initiative will positively impact healthcare costs, quality, and patient safety. Secure institutional support to hold meetings and set specific goals.

And, remember, starting a Choosing Wisely project takes time and commitment. There must be a period of deliberate infrastructure building in which protocols that facilitate Choosing Wisely practices are put in place and metrics for measuring their success are established. Only when this foundation is properly laid can the initiatives be truly and perceptively effective.

Securing institutional support is the first step in any Choosing Wisely project. Evaluate your hospital in the areas covered by Choosing Wisely recommendations. How does the number of transfusions occurring in your hospital compare to national averages? What about number of catheter days and frequency of CAUTIs?

Once you choose an area for improvement, present a strong business case, strongly supported by data and the best projections you can muster, to your hospital’s stakeholders to prove that your proposed initiative will positively impact healthcare costs, quality, and patient safety. Secure institutional support to hold meetings and set specific goals.

And, remember, starting a Choosing Wisely project takes time and commitment. There must be a period of deliberate infrastructure building in which protocols that facilitate Choosing Wisely practices are put in place and metrics for measuring their success are established. Only when this foundation is properly laid can the initiatives be truly and perceptively effective.

Securing institutional support is the first step in any Choosing Wisely project. Evaluate your hospital in the areas covered by Choosing Wisely recommendations. How does the number of transfusions occurring in your hospital compare to national averages? What about number of catheter days and frequency of CAUTIs?

Once you choose an area for improvement, present a strong business case, strongly supported by data and the best projections you can muster, to your hospital’s stakeholders to prove that your proposed initiative will positively impact healthcare costs, quality, and patient safety. Secure institutional support to hold meetings and set specific goals.

And, remember, starting a Choosing Wisely project takes time and commitment. There must be a period of deliberate infrastructure building in which protocols that facilitate Choosing Wisely practices are put in place and metrics for measuring their success are established. Only when this foundation is properly laid can the initiatives be truly and perceptively effective.

ICD-10 is the system that will replace ICD-9 for all parties covered by the Health Insurance Portability and Accountability Act (HIPAA). ICD-10 contains a code set used for inpatient procedural reporting and a code set used for diagnosis reporting. Physicians billing for professional services will only be affected when reporting diagnoses codes on their claims, but both physician and hospital selection of ICD-10 codes relies heavily on physician documentation. Therefore, documentation must be scrutinized. The most widely noted impact ICD-10 will have on documentation is increased specificity, with enhanced reporting of the patient’s presenting problem(s). Expanding from a pool of 14,000 3/5-digit codes to 69,000 7-digit codes, and accommodating this change, are daunting tasks. These anticipated burdens make it hard for physicians to recognize the positive effects ICD-10 may create, such as:¹

• Better clinical decisions as better data is documented, collected, and evaluated;
• Improved protocol and clinical pathway design for various health conditions;
• Improved public health reporting and tracking of illnesses and severity over time;
• Better definition of patient conditions, providing improved matching of professional resources and care teams and increasing communications between providers;
• Support in practice transition to risk-sharing models with more precise data for patients and populations;
• Provision of clear objective data for credentialing and privileges, and support for professional Maintenance of Certification reporting across specialties;
• Better documentation of patient complexity and level of care, supporting reimbursement and measures for quality and efficiency reporting; and
• Reduction in audit risk exposure by encouraging the use of diagnosis codes with a greater degree of specificity as supported by the clinical documentation.

With the Oct. 1 implementation date rapidly approaching, physicians need to ask themselves, “Am I prepared?”

Getting Started

Everyone has a role and responsibility in transitioning to ICD-10. Active participation by all involved parties guarantees a more successful outcome. Practice administration must ensure that each aspect of implementation is reviewed and appropriately addressed. If not already done, immediate steps should be taken to verify the products and services that affect implementation. These include:

• Payer mix and related contracts: Entities not covered by HIPAA (e.g. workers’ compensation and auto insurance companies) may choose not to implement ICD-10. Since ICD-9 will no longer be maintained post-ICD-10 implementation, it is in the best interest of non-covered entities to use the new coding system.² For payers who are required to transition to ICD-10, it is important to identify whether patient eligibility, claim processing, and/or payment timelines will be affected, as well as fee schedules or capitated rates.
• Vendor readiness: Physician groups may use a variety of vendors to assist with different aspects of the revenue cycle, including an electronic health record (e.g. documenting services and transmitting physician orders/prescriptions); a practice management system (e.g. scheduling and registering patients); a billing service (e.g. processing patient claims and payments); and a clearinghouse (e.g. verifying patient eligibility and obtaining authorizations). Know when software and/or hardware upgrades are available and if there are additional upgrade fees. Identify vendors that provide support services, training, and tools or templates to ease the transition. Most importantly, inquire about a testing period for products and applications to ensure functionality and adequate feedback on use of the system(s).
• Internal coding and billing resources. Identify physicians and staff who use ICD-9 codes and need to know ICD-10 codes in order to fulfill their responsibilities. Both physicians and staff can assist in identifying common clinical scenarios and the most frequently used ICD-9 codes, in order to develop a list of common ICD-10 specialty codes. Payer coverage policies currently include ICD-10 codes for provider review and comparison. Revise current forms/templates that include diagnosis codes to reflect this updated information. Schedule ICD-10 training for clinicians, office managers, billers, coders, and other key staff. Coding professionals recommend that training take place approximately six months prior to the ICD-10 compliance deadline.³ Training sessions are available from consultants, professional societies, payers, and other entities. Cost varies depending upon the type and length of training. CMS provides some free services, but in-depth training or certification for at least one practice member should be considered.

Once training is completed, dual coding is an option. Dual coding is the process by which both ICD-9 codes and ICD-10 codes are selected during the coding process. Some practices rely on independent selection of each code, while others rely on the General Equivalence Mappings (GEMs). GEMs were developed to assist industry migration to ICD-10. They are intended to be used primarily for translations of code lists or code tables used by an application or other coded data when codes in one code set are the only source of information; they are not intended as a substitution for direct use of ICD-9-CM and ICD-10-CM/PCS.⁴ Manual coding enhances coding efficiency and also identifies physician documentation deficiencies. Dual coding should begin as soon as possible, prior to October 1.

End-to-end testing is an opportunity to submit test claims to CMS with ICD-10 codes; providers will receive a remittance advice that explains the adjudication of the claims.⁵ This testing is limited to a small group of providers who were required to register in April, and its final week is July 20-24.

Provide Feedback

The importance of feedback is often understated. Many physician practices do not have the time to plan ahead and, as a result, find themselves in a reactive rather than proactive role. Over the next couple of months, find the time and resources to audit physician documentation based on ICD-10 criteria. Ask yourself whether or not the information contains enough specificity to select the best possible code, or does code selection default to an “unspecified” code?

Avoid “unspecified” codes when possible in preparation for payer policy revisions that are aimed at reducing or eliminating these types of codes. If the documentation lacks detail, educate physicians on the missing elements.

Review ICD-10 code sets with physicians to improve their understanding of the new system. For example, diabetes mellitus is identified in ICD-9 as one category (250.xx), with digits to specify Type I or Type II, controlled vs. uncontrolled, with or without complications. ICD-10 separates diabetes into categories of Type I (E10) or Type II (E11), with subcategories to identify complications and affected body systems, thereby expanding the volume of codes and corresponding documentation criteria.⁶

Post-implementation feedback will become even more important. Monitor claim denials for invalid codes and medical necessity issues (i.e., valid codes not included for coverage). If the medical necessity denials are a result of inaccurate code selection related to insufficient documentation details, provider education will be crucial in resolving these errors. Continuing education to strengthen and update staff skills is imperative.

CMS has developed many tools and resources to promote a successful transition and assess your ICD-10 preparedness. Physician practices can develop an “action plan,” learn basic ICD-10 concepts, and much more.

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. Centers for Medicare and Medicaid Services. Road to 10: the small physician practice’s route to ICD-10? Accessed June 6, 2015.
2. Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicare Learning Network: ICD-10-CM/PCS Myths and Facts. Accessed June 6, 2015.
3. Centers for Medicare and Medicaid Services. ICD-10: ICD-10 Basics for Medical Practices. Accessed June 6, 2015.
4. American Health Information Management Association (AHIMA). Putting the ICD-10-CM/PCS GEMs into practice. Accessed June 6, 2015.
5. Novitas Solutions. Medicare JL, Part B. ICD-10 Implementation. Accessed June 6, 2015.
6. Centers for Medicare and Medicaid Services. ICD-10 Coding and Diabetes. Accessed June 6, 2015.

ICD-10 is the system that will replace ICD-9 for all parties covered by the Health Insurance Portability and Accountability Act (HIPAA). ICD-10 contains a code set used for inpatient procedural reporting and a code set used for diagnosis reporting. Physicians billing for professional services will only be affected when reporting diagnoses codes on their claims, but both physician and hospital selection of ICD-10 codes relies heavily on physician documentation. Therefore, documentation must be scrutinized. The most widely noted impact ICD-10 will have on documentation is increased specificity, with enhanced reporting of the patient’s presenting problem(s). Expanding from a pool of 14,000 3/5-digit codes to 69,000 7-digit codes, and accommodating this change, are daunting tasks. These anticipated burdens make it hard for physicians to recognize the positive effects ICD-10 may create, such as:¹

• Better clinical decisions as better data is documented, collected, and evaluated;
• Improved protocol and clinical pathway design for various health conditions;
• Improved public health reporting and tracking of illnesses and severity over time;
• Better definition of patient conditions, providing improved matching of professional resources and care teams and increasing communications between providers;
• Support in practice transition to risk-sharing models with more precise data for patients and populations;
• Provision of clear objective data for credentialing and privileges, and support for professional Maintenance of Certification reporting across specialties;
• Better documentation of patient complexity and level of care, supporting reimbursement and measures for quality and efficiency reporting; and
• Reduction in audit risk exposure by encouraging the use of diagnosis codes with a greater degree of specificity as supported by the clinical documentation.

With the Oct. 1 implementation date rapidly approaching, physicians need to ask themselves, “Am I prepared?”

Getting Started

Everyone has a role and responsibility in transitioning to ICD-10. Active participation by all involved parties guarantees a more successful outcome. Practice administration must ensure that each aspect of implementation is reviewed and appropriately addressed. If not already done, immediate steps should be taken to verify the products and services that affect implementation. These include:

• Payer mix and related contracts: Entities not covered by HIPAA (e.g. workers’ compensation and auto insurance companies) may choose not to implement ICD-10. Since ICD-9 will no longer be maintained post-ICD-10 implementation, it is in the best interest of non-covered entities to use the new coding system.² For payers who are required to transition to ICD-10, it is important to identify whether patient eligibility, claim processing, and/or payment timelines will be affected, as well as fee schedules or capitated rates.
• Vendor readiness: Physician groups may use a variety of vendors to assist with different aspects of the revenue cycle, including an electronic health record (e.g. documenting services and transmitting physician orders/prescriptions); a practice management system (e.g. scheduling and registering patients); a billing service (e.g. processing patient claims and payments); and a clearinghouse (e.g. verifying patient eligibility and obtaining authorizations). Know when software and/or hardware upgrades are available and if there are additional upgrade fees. Identify vendors that provide support services, training, and tools or templates to ease the transition. Most importantly, inquire about a testing period for products and applications to ensure functionality and adequate feedback on use of the system(s).
• Internal coding and billing resources. Identify physicians and staff who use ICD-9 codes and need to know ICD-10 codes in order to fulfill their responsibilities. Both physicians and staff can assist in identifying common clinical scenarios and the most frequently used ICD-9 codes, in order to develop a list of common ICD-10 specialty codes. Payer coverage policies currently include ICD-10 codes for provider review and comparison. Revise current forms/templates that include diagnosis codes to reflect this updated information. Schedule ICD-10 training for clinicians, office managers, billers, coders, and other key staff. Coding professionals recommend that training take place approximately six months prior to the ICD-10 compliance deadline.³ Training sessions are available from consultants, professional societies, payers, and other entities. Cost varies depending upon the type and length of training. CMS provides some free services, but in-depth training or certification for at least one practice member should be considered.

Once training is completed, dual coding is an option. Dual coding is the process by which both ICD-9 codes and ICD-10 codes are selected during the coding process. Some practices rely on independent selection of each code, while others rely on the General Equivalence Mappings (GEMs). GEMs were developed to assist industry migration to ICD-10. They are intended to be used primarily for translations of code lists or code tables used by an application or other coded data when codes in one code set are the only source of information; they are not intended as a substitution for direct use of ICD-9-CM and ICD-10-CM/PCS.⁴ Manual coding enhances coding efficiency and also identifies physician documentation deficiencies. Dual coding should begin as soon as possible, prior to October 1.

End-to-end testing is an opportunity to submit test claims to CMS with ICD-10 codes; providers will receive a remittance advice that explains the adjudication of the claims.⁵ This testing is limited to a small group of providers who were required to register in April, and its final week is July 20-24.

Provide Feedback

The importance of feedback is often understated. Many physician practices do not have the time to plan ahead and, as a result, find themselves in a reactive rather than proactive role. Over the next couple of months, find the time and resources to audit physician documentation based on ICD-10 criteria. Ask yourself whether or not the information contains enough specificity to select the best possible code, or does code selection default to an “unspecified” code?

Avoid “unspecified” codes when possible in preparation for payer policy revisions that are aimed at reducing or eliminating these types of codes. If the documentation lacks detail, educate physicians on the missing elements.

Review ICD-10 code sets with physicians to improve their understanding of the new system. For example, diabetes mellitus is identified in ICD-9 as one category (250.xx), with digits to specify Type I or Type II, controlled vs. uncontrolled, with or without complications. ICD-10 separates diabetes into categories of Type I (E10) or Type II (E11), with subcategories to identify complications and affected body systems, thereby expanding the volume of codes and corresponding documentation criteria.⁶

Post-implementation feedback will become even more important. Monitor claim denials for invalid codes and medical necessity issues (i.e., valid codes not included for coverage). If the medical necessity denials are a result of inaccurate code selection related to insufficient documentation details, provider education will be crucial in resolving these errors. Continuing education to strengthen and update staff skills is imperative.

CMS has developed many tools and resources to promote a successful transition and assess your ICD-10 preparedness. Physician practices can develop an “action plan,” learn basic ICD-10 concepts, and much more.

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. Centers for Medicare and Medicaid Services. Road to 10: the small physician practice’s route to ICD-10? Accessed June 6, 2015.
2. Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicare Learning Network: ICD-10-CM/PCS Myths and Facts. Accessed June 6, 2015.
3. Centers for Medicare and Medicaid Services. ICD-10: ICD-10 Basics for Medical Practices. Accessed June 6, 2015.
4. American Health Information Management Association (AHIMA). Putting the ICD-10-CM/PCS GEMs into practice. Accessed June 6, 2015.
5. Novitas Solutions. Medicare JL, Part B. ICD-10 Implementation. Accessed June 6, 2015.
6. Centers for Medicare and Medicaid Services. ICD-10 Coding and Diabetes. Accessed June 6, 2015.

ICD-10 is the system that will replace ICD-9 for all parties covered by the Health Insurance Portability and Accountability Act (HIPAA). ICD-10 contains a code set used for inpatient procedural reporting and a code set used for diagnosis reporting. Physicians billing for professional services will only be affected when reporting diagnoses codes on their claims, but both physician and hospital selection of ICD-10 codes relies heavily on physician documentation. Therefore, documentation must be scrutinized. The most widely noted impact ICD-10 will have on documentation is increased specificity, with enhanced reporting of the patient’s presenting problem(s). Expanding from a pool of 14,000 3/5-digit codes to 69,000 7-digit codes, and accommodating this change, are daunting tasks. These anticipated burdens make it hard for physicians to recognize the positive effects ICD-10 may create, such as:¹

• Better clinical decisions as better data is documented, collected, and evaluated;
• Improved protocol and clinical pathway design for various health conditions;
• Improved public health reporting and tracking of illnesses and severity over time;
• Better definition of patient conditions, providing improved matching of professional resources and care teams and increasing communications between providers;
• Support in practice transition to risk-sharing models with more precise data for patients and populations;
• Provision of clear objective data for credentialing and privileges, and support for professional Maintenance of Certification reporting across specialties;
• Better documentation of patient complexity and level of care, supporting reimbursement and measures for quality and efficiency reporting; and
• Reduction in audit risk exposure by encouraging the use of diagnosis codes with a greater degree of specificity as supported by the clinical documentation.

With the Oct. 1 implementation date rapidly approaching, physicians need to ask themselves, “Am I prepared?”

Getting Started

Everyone has a role and responsibility in transitioning to ICD-10. Active participation by all involved parties guarantees a more successful outcome. Practice administration must ensure that each aspect of implementation is reviewed and appropriately addressed. If not already done, immediate steps should be taken to verify the products and services that affect implementation. These include:

• Payer mix and related contracts: Entities not covered by HIPAA (e.g. workers’ compensation and auto insurance companies) may choose not to implement ICD-10. Since ICD-9 will no longer be maintained post-ICD-10 implementation, it is in the best interest of non-covered entities to use the new coding system.² For payers who are required to transition to ICD-10, it is important to identify whether patient eligibility, claim processing, and/or payment timelines will be affected, as well as fee schedules or capitated rates.
• Vendor readiness: Physician groups may use a variety of vendors to assist with different aspects of the revenue cycle, including an electronic health record (e.g. documenting services and transmitting physician orders/prescriptions); a practice management system (e.g. scheduling and registering patients); a billing service (e.g. processing patient claims and payments); and a clearinghouse (e.g. verifying patient eligibility and obtaining authorizations). Know when software and/or hardware upgrades are available and if there are additional upgrade fees. Identify vendors that provide support services, training, and tools or templates to ease the transition. Most importantly, inquire about a testing period for products and applications to ensure functionality and adequate feedback on use of the system(s).
• Internal coding and billing resources. Identify physicians and staff who use ICD-9 codes and need to know ICD-10 codes in order to fulfill their responsibilities. Both physicians and staff can assist in identifying common clinical scenarios and the most frequently used ICD-9 codes, in order to develop a list of common ICD-10 specialty codes. Payer coverage policies currently include ICD-10 codes for provider review and comparison. Revise current forms/templates that include diagnosis codes to reflect this updated information. Schedule ICD-10 training for clinicians, office managers, billers, coders, and other key staff. Coding professionals recommend that training take place approximately six months prior to the ICD-10 compliance deadline.³ Training sessions are available from consultants, professional societies, payers, and other entities. Cost varies depending upon the type and length of training. CMS provides some free services, but in-depth training or certification for at least one practice member should be considered.

Once training is completed, dual coding is an option. Dual coding is the process by which both ICD-9 codes and ICD-10 codes are selected during the coding process. Some practices rely on independent selection of each code, while others rely on the General Equivalence Mappings (GEMs). GEMs were developed to assist industry migration to ICD-10. They are intended to be used primarily for translations of code lists or code tables used by an application or other coded data when codes in one code set are the only source of information; they are not intended as a substitution for direct use of ICD-9-CM and ICD-10-CM/PCS.⁴ Manual coding enhances coding efficiency and also identifies physician documentation deficiencies. Dual coding should begin as soon as possible, prior to October 1.

End-to-end testing is an opportunity to submit test claims to CMS with ICD-10 codes; providers will receive a remittance advice that explains the adjudication of the claims.⁵ This testing is limited to a small group of providers who were required to register in April, and its final week is July 20-24.

Provide Feedback

The importance of feedback is often understated. Many physician practices do not have the time to plan ahead and, as a result, find themselves in a reactive rather than proactive role. Over the next couple of months, find the time and resources to audit physician documentation based on ICD-10 criteria. Ask yourself whether or not the information contains enough specificity to select the best possible code, or does code selection default to an “unspecified” code?

Avoid “unspecified” codes when possible in preparation for payer policy revisions that are aimed at reducing or eliminating these types of codes. If the documentation lacks detail, educate physicians on the missing elements.

Review ICD-10 code sets with physicians to improve their understanding of the new system. For example, diabetes mellitus is identified in ICD-9 as one category (250.xx), with digits to specify Type I or Type II, controlled vs. uncontrolled, with or without complications. ICD-10 separates diabetes into categories of Type I (E10) or Type II (E11), with subcategories to identify complications and affected body systems, thereby expanding the volume of codes and corresponding documentation criteria.⁶

Post-implementation feedback will become even more important. Monitor claim denials for invalid codes and medical necessity issues (i.e., valid codes not included for coverage). If the medical necessity denials are a result of inaccurate code selection related to insufficient documentation details, provider education will be crucial in resolving these errors. Continuing education to strengthen and update staff skills is imperative.

CMS has developed many tools and resources to promote a successful transition and assess your ICD-10 preparedness. Physician practices can develop an “action plan,” learn basic ICD-10 concepts, and much more.

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. Centers for Medicare and Medicaid Services. Road to 10: the small physician practice’s route to ICD-10? Accessed June 6, 2015.
2. Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicare Learning Network: ICD-10-CM/PCS Myths and Facts. Accessed June 6, 2015.
3. Centers for Medicare and Medicaid Services. ICD-10: ICD-10 Basics for Medical Practices. Accessed June 6, 2015.
4. American Health Information Management Association (AHIMA). Putting the ICD-10-CM/PCS GEMs into practice. Accessed June 6, 2015.
5. Novitas Solutions. Medicare JL, Part B. ICD-10 Implementation. Accessed June 6, 2015.
6. Centers for Medicare and Medicaid Services. ICD-10 Coding and Diabetes. Accessed June 6, 2015.