Hospital medicine leaders have long acknowledged the disconnects in medical care that occur at discharge. The demand for greater efficiency in hospital-based care is what has driven the hospitalist movement and its inexorable growth the past two decades.

Efforts to overcome discontinuity of care have included more timely discharge summaries, phone calls to primary care physicians (PCPs) and specialists at the time of discharge, and hospitalist-staffed post-discharge clinics. In a 2002 article, Robert Wachter, MD, MHM, and Steven Pantilat, MD, SFHM, of the University of California San Francisco (UCSF), suggested that PCPs make continuity visits to the hospital once or twice to maintain their involvement and help coordinate the care of their patients.¹

A new “Perspectives” piece in The New England Journal of Medicine proposes that PCPs act as medical consultants to the hospitalist team while their patients are in the hospital, making a consulting visit “within 12 to 18 hours after admission to provide support and continuity to them and their families.”² Authors Allan Goroll, MD, MACP, and Daniel Hunt, MD, propose that the PCP be asked to write a succinct consultation note in the hospital chart, highlighting key elements of the patient’s history and recent tests—with the goal of complementing and informing the hospitalist’s admission workup and care plan—while being paid as a consultant.

“It’s a fairly straightforward proposal,” says Dr. Hunt, chief of the hospital medicine unit at Massachusetts General Hospital (MGH) in Boston. “We’re not looking for PCPs to take care of every aspect of inpatient care. It’s really just to bring in the PCP’s expertise and nuanced understanding of the patient at a vulnerable time for the patient.”

The idea might seem a little ironic given the fact that hospitalists were created in part to relieve busy PCPs from having to visit the hospital. But some see it as a way forward.

“I wouldn’t call it a step backward,” says Joseph Ming Wah Li, MD, SFHM, FACP, director of the hospital medicine program at Beth Israel Deaconess Medical Center (BIDMC) in Boston and a former SHM president. “Is it feasible? Realistically, in most settings today, I don’t think it is. But I would love it. I don’t really know enough about the patients I take care of in the hospital.”

The Barrier of “Not Enough Time”

Dr. Hunt says the biggest barrier to this proposal is the time that PCPs would have to carve out to make physical trips to the hospital.

“That ultimately comes down to reimbursement,” he says.

MGH, which is well situated with medical practices in or near the main hospital building, has piloted an approach similar to the NEJM proposal with a primary care group that comes in to see its patients in the first day or two after admission and then again on the day before discharge.

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs. That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”–Dr. Hunt

“But they are essentially doing it out of the goodness of their hearts,” Dr. Hunt explains. “What we’ve seen from this experiment are much better transitions of care and much better decision making around big decisions, such as end-of-life care or surgical interventions.”

Hospitalists at MGH and the PCPs spent a year and a half talking through the specifics of how their arrangement would work.

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs,” he says. “That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”

Dr. Hunt says the key is recognizing the “huge” value PCPs bring to an inpatient stay. And, while physical trips to the hospital or e-mails might not work for every hospitalist or PCP, the connecting of information and insight is often worth the investment.

“There are other ways [to communicate], such as video conferencing and Skype, where doctors could participate more efficiently in the care of their hospitalized patients,” he says, adding that hospitalists should reach out to PCPs, both when a patient enters the hospital and as part of a larger discussion about how to improve communication and continuity of care.

The PCP Perspective

Boston internist Gila Kriegel, MD, might seem like a throwback. She says she wants to visit her patients when they are in the hospital, if at all possible. In fact, hospitalists in Boston say Dr. Kriegel allows them to take care of her patients “almost begrudgingly.”

“She is so involved in their care,” Dr. Li says. “She tells me everything I need to know about them. She’d be here every day if she weren’t juggling other responsibilities.”

A PCP since 1986, Dr. Kriegel’s story illustrates the complexities of an evolving healthcare system. She’s based in an academic setting, which she calls a “kind of ivory tower.”

“But I was fortunate in 1989, after my first son was born and I went part-time, to have a colleague who offered to see my inpatients on the days I wasn’t working,” she explains. “Then a woman colleague of mine also went part-time, and we agreed to cross-cover for each other.”

Eventually, Dr. Kriegel was approached by Dr. Li’s hospitalist group, which offered to manage her hospitalized patients.

“For the first six months to a year, I’d go see my patients in the hospital on a social visit. I’d even write notes in the chart, until they told me, ‘You are not responsible for the care in the hospital. The hospitalist is,’” she recalls. “For me, it was a big loss to stop going to the hospital. Most PCPs I know like seeing their patients through the course of the illness.”

Then again, she also admits how difficult it is to see her patients in the hospital.

Still, she managed to stay connected. “When I stopped going to see my patients, I asked the hospital staff to give me the patient’s bedside phone number, and I’d call them in the hospital to let them know I was up on what was happening,” she says.

Technology, coincidentally, inserted a barrier: She wasn’t able to access hospitalists’ daily notes in the BIDMC electronic health records. That’s when Dr. Kriegel began e-mailing the hospitalists. In the end, even that form of communication wasn’t fully satisfying.

“The current system requires me to do the outreach,” she explains. “If you ask hospitalists about communication, they’d say they’re already doing it. But a discharge summary isn’t the same as knowing in real time what’s happening with my patients.”

“I’d love to make virtual visits to the patient in the hospital, by phone or computer link—even more so if I could get paid for my time. But I want to stay involved.”

Ripe for Innovation

Dr. Wachter, chief of hospital medicine at UCSF, who writes an HM-focused blog [wachtersworld.com], says the continuity visit is a good idea but also understands the difficulties in the new healthcare paradigm.

“It’s not easy to work out the logistics, and it depends on the geography,” he says. “We also need to be considering telemedicine. But something to enhance continuity is ripe for innovation.”

He says consultation or continuity visits offer ways to improve care with a relatively small expenditure.

“We still see a few PCPs come in when their patients are hospitalized. It’s very reassuring to their patients,” he says. “For the complicated cases where an ongoing relationship matters, those encounters are fabulous.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Goroll AH, Hunt DP. Bridging the hospitalist-primary care divide through collaborative care. New Engl J Med. 2015;372(4):308-309.
2. Wachter RM, Pantilat SZ. The “continuity visit” and the hospitalist model of care. Dis Mon. 2002;48(4):267-272.

Hospital medicine leaders have long acknowledged the disconnects in medical care that occur at discharge. The demand for greater efficiency in hospital-based care is what has driven the hospitalist movement and its inexorable growth the past two decades.

Efforts to overcome discontinuity of care have included more timely discharge summaries, phone calls to primary care physicians (PCPs) and specialists at the time of discharge, and hospitalist-staffed post-discharge clinics. In a 2002 article, Robert Wachter, MD, MHM, and Steven Pantilat, MD, SFHM, of the University of California San Francisco (UCSF), suggested that PCPs make continuity visits to the hospital once or twice to maintain their involvement and help coordinate the care of their patients.¹

A new “Perspectives” piece in The New England Journal of Medicine proposes that PCPs act as medical consultants to the hospitalist team while their patients are in the hospital, making a consulting visit “within 12 to 18 hours after admission to provide support and continuity to them and their families.”² Authors Allan Goroll, MD, MACP, and Daniel Hunt, MD, propose that the PCP be asked to write a succinct consultation note in the hospital chart, highlighting key elements of the patient’s history and recent tests—with the goal of complementing and informing the hospitalist’s admission workup and care plan—while being paid as a consultant.

“It’s a fairly straightforward proposal,” says Dr. Hunt, chief of the hospital medicine unit at Massachusetts General Hospital (MGH) in Boston. “We’re not looking for PCPs to take care of every aspect of inpatient care. It’s really just to bring in the PCP’s expertise and nuanced understanding of the patient at a vulnerable time for the patient.”

The idea might seem a little ironic given the fact that hospitalists were created in part to relieve busy PCPs from having to visit the hospital. But some see it as a way forward.

“I wouldn’t call it a step backward,” says Joseph Ming Wah Li, MD, SFHM, FACP, director of the hospital medicine program at Beth Israel Deaconess Medical Center (BIDMC) in Boston and a former SHM president. “Is it feasible? Realistically, in most settings today, I don’t think it is. But I would love it. I don’t really know enough about the patients I take care of in the hospital.”

The Barrier of “Not Enough Time”

Dr. Hunt says the biggest barrier to this proposal is the time that PCPs would have to carve out to make physical trips to the hospital.

“That ultimately comes down to reimbursement,” he says.

MGH, which is well situated with medical practices in or near the main hospital building, has piloted an approach similar to the NEJM proposal with a primary care group that comes in to see its patients in the first day or two after admission and then again on the day before discharge.

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs. That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”–Dr. Hunt

“But they are essentially doing it out of the goodness of their hearts,” Dr. Hunt explains. “What we’ve seen from this experiment are much better transitions of care and much better decision making around big decisions, such as end-of-life care or surgical interventions.”

Hospitalists at MGH and the PCPs spent a year and a half talking through the specifics of how their arrangement would work.

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs,” he says. “That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”

Dr. Hunt says the key is recognizing the “huge” value PCPs bring to an inpatient stay. And, while physical trips to the hospital or e-mails might not work for every hospitalist or PCP, the connecting of information and insight is often worth the investment.

“There are other ways [to communicate], such as video conferencing and Skype, where doctors could participate more efficiently in the care of their hospitalized patients,” he says, adding that hospitalists should reach out to PCPs, both when a patient enters the hospital and as part of a larger discussion about how to improve communication and continuity of care.

The PCP Perspective

Boston internist Gila Kriegel, MD, might seem like a throwback. She says she wants to visit her patients when they are in the hospital, if at all possible. In fact, hospitalists in Boston say Dr. Kriegel allows them to take care of her patients “almost begrudgingly.”

“She is so involved in their care,” Dr. Li says. “She tells me everything I need to know about them. She’d be here every day if she weren’t juggling other responsibilities.”

A PCP since 1986, Dr. Kriegel’s story illustrates the complexities of an evolving healthcare system. She’s based in an academic setting, which she calls a “kind of ivory tower.”

“But I was fortunate in 1989, after my first son was born and I went part-time, to have a colleague who offered to see my inpatients on the days I wasn’t working,” she explains. “Then a woman colleague of mine also went part-time, and we agreed to cross-cover for each other.”

Eventually, Dr. Kriegel was approached by Dr. Li’s hospitalist group, which offered to manage her hospitalized patients.

“For the first six months to a year, I’d go see my patients in the hospital on a social visit. I’d even write notes in the chart, until they told me, ‘You are not responsible for the care in the hospital. The hospitalist is,’” she recalls. “For me, it was a big loss to stop going to the hospital. Most PCPs I know like seeing their patients through the course of the illness.”

Then again, she also admits how difficult it is to see her patients in the hospital.

Still, she managed to stay connected. “When I stopped going to see my patients, I asked the hospital staff to give me the patient’s bedside phone number, and I’d call them in the hospital to let them know I was up on what was happening,” she says.

Technology, coincidentally, inserted a barrier: She wasn’t able to access hospitalists’ daily notes in the BIDMC electronic health records. That’s when Dr. Kriegel began e-mailing the hospitalists. In the end, even that form of communication wasn’t fully satisfying.

“The current system requires me to do the outreach,” she explains. “If you ask hospitalists about communication, they’d say they’re already doing it. But a discharge summary isn’t the same as knowing in real time what’s happening with my patients.”

“I’d love to make virtual visits to the patient in the hospital, by phone or computer link—even more so if I could get paid for my time. But I want to stay involved.”

Ripe for Innovation

Dr. Wachter, chief of hospital medicine at UCSF, who writes an HM-focused blog [wachtersworld.com], says the continuity visit is a good idea but also understands the difficulties in the new healthcare paradigm.

“It’s not easy to work out the logistics, and it depends on the geography,” he says. “We also need to be considering telemedicine. But something to enhance continuity is ripe for innovation.”

He says consultation or continuity visits offer ways to improve care with a relatively small expenditure.

“We still see a few PCPs come in when their patients are hospitalized. It’s very reassuring to their patients,” he says. “For the complicated cases where an ongoing relationship matters, those encounters are fabulous.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Goroll AH, Hunt DP. Bridging the hospitalist-primary care divide through collaborative care. New Engl J Med. 2015;372(4):308-309.
2. Wachter RM, Pantilat SZ. The “continuity visit” and the hospitalist model of care. Dis Mon. 2002;48(4):267-272.

Hospital medicine leaders have long acknowledged the disconnects in medical care that occur at discharge. The demand for greater efficiency in hospital-based care is what has driven the hospitalist movement and its inexorable growth the past two decades.

Efforts to overcome discontinuity of care have included more timely discharge summaries, phone calls to primary care physicians (PCPs) and specialists at the time of discharge, and hospitalist-staffed post-discharge clinics. In a 2002 article, Robert Wachter, MD, MHM, and Steven Pantilat, MD, SFHM, of the University of California San Francisco (UCSF), suggested that PCPs make continuity visits to the hospital once or twice to maintain their involvement and help coordinate the care of their patients.¹

A new “Perspectives” piece in The New England Journal of Medicine proposes that PCPs act as medical consultants to the hospitalist team while their patients are in the hospital, making a consulting visit “within 12 to 18 hours after admission to provide support and continuity to them and their families.”² Authors Allan Goroll, MD, MACP, and Daniel Hunt, MD, propose that the PCP be asked to write a succinct consultation note in the hospital chart, highlighting key elements of the patient’s history and recent tests—with the goal of complementing and informing the hospitalist’s admission workup and care plan—while being paid as a consultant.

“It’s a fairly straightforward proposal,” says Dr. Hunt, chief of the hospital medicine unit at Massachusetts General Hospital (MGH) in Boston. “We’re not looking for PCPs to take care of every aspect of inpatient care. It’s really just to bring in the PCP’s expertise and nuanced understanding of the patient at a vulnerable time for the patient.”

The idea might seem a little ironic given the fact that hospitalists were created in part to relieve busy PCPs from having to visit the hospital. But some see it as a way forward.

“I wouldn’t call it a step backward,” says Joseph Ming Wah Li, MD, SFHM, FACP, director of the hospital medicine program at Beth Israel Deaconess Medical Center (BIDMC) in Boston and a former SHM president. “Is it feasible? Realistically, in most settings today, I don’t think it is. But I would love it. I don’t really know enough about the patients I take care of in the hospital.”

The Barrier of “Not Enough Time”

Dr. Hunt says the biggest barrier to this proposal is the time that PCPs would have to carve out to make physical trips to the hospital.

“That ultimately comes down to reimbursement,” he says.

MGH, which is well situated with medical practices in or near the main hospital building, has piloted an approach similar to the NEJM proposal with a primary care group that comes in to see its patients in the first day or two after admission and then again on the day before discharge.

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs. That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”–Dr. Hunt

“But they are essentially doing it out of the goodness of their hearts,” Dr. Hunt explains. “What we’ve seen from this experiment are much better transitions of care and much better decision making around big decisions, such as end-of-life care or surgical interventions.”

Hospitalists at MGH and the PCPs spent a year and a half talking through the specifics of how their arrangement would work.

“We made a commitment, as hospitalists, to communicate directly by phone with the PCPs,” he says. “That commitment lasted about a week, and then we quickly converted to a daily e-mail. That works, because both parties are communicating substantial information in these e-mails.”

Dr. Hunt says the key is recognizing the “huge” value PCPs bring to an inpatient stay. And, while physical trips to the hospital or e-mails might not work for every hospitalist or PCP, the connecting of information and insight is often worth the investment.

“There are other ways [to communicate], such as video conferencing and Skype, where doctors could participate more efficiently in the care of their hospitalized patients,” he says, adding that hospitalists should reach out to PCPs, both when a patient enters the hospital and as part of a larger discussion about how to improve communication and continuity of care.

The PCP Perspective

Boston internist Gila Kriegel, MD, might seem like a throwback. She says she wants to visit her patients when they are in the hospital, if at all possible. In fact, hospitalists in Boston say Dr. Kriegel allows them to take care of her patients “almost begrudgingly.”

“She is so involved in their care,” Dr. Li says. “She tells me everything I need to know about them. She’d be here every day if she weren’t juggling other responsibilities.”

A PCP since 1986, Dr. Kriegel’s story illustrates the complexities of an evolving healthcare system. She’s based in an academic setting, which she calls a “kind of ivory tower.”

“But I was fortunate in 1989, after my first son was born and I went part-time, to have a colleague who offered to see my inpatients on the days I wasn’t working,” she explains. “Then a woman colleague of mine also went part-time, and we agreed to cross-cover for each other.”

Eventually, Dr. Kriegel was approached by Dr. Li’s hospitalist group, which offered to manage her hospitalized patients.

“For the first six months to a year, I’d go see my patients in the hospital on a social visit. I’d even write notes in the chart, until they told me, ‘You are not responsible for the care in the hospital. The hospitalist is,’” she recalls. “For me, it was a big loss to stop going to the hospital. Most PCPs I know like seeing their patients through the course of the illness.”

Then again, she also admits how difficult it is to see her patients in the hospital.

Still, she managed to stay connected. “When I stopped going to see my patients, I asked the hospital staff to give me the patient’s bedside phone number, and I’d call them in the hospital to let them know I was up on what was happening,” she says.

Technology, coincidentally, inserted a barrier: She wasn’t able to access hospitalists’ daily notes in the BIDMC electronic health records. That’s when Dr. Kriegel began e-mailing the hospitalists. In the end, even that form of communication wasn’t fully satisfying.

“The current system requires me to do the outreach,” she explains. “If you ask hospitalists about communication, they’d say they’re already doing it. But a discharge summary isn’t the same as knowing in real time what’s happening with my patients.”

“I’d love to make virtual visits to the patient in the hospital, by phone or computer link—even more so if I could get paid for my time. But I want to stay involved.”

Ripe for Innovation

Dr. Wachter, chief of hospital medicine at UCSF, who writes an HM-focused blog [wachtersworld.com], says the continuity visit is a good idea but also understands the difficulties in the new healthcare paradigm.

“It’s not easy to work out the logistics, and it depends on the geography,” he says. “We also need to be considering telemedicine. But something to enhance continuity is ripe for innovation.”

He says consultation or continuity visits offer ways to improve care with a relatively small expenditure.

“We still see a few PCPs come in when their patients are hospitalized. It’s very reassuring to their patients,” he says. “For the complicated cases where an ongoing relationship matters, those encounters are fabulous.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Goroll AH, Hunt DP. Bridging the hospitalist-primary care divide through collaborative care. New Engl J Med. 2015;372(4):308-309.
2. Wachter RM, Pantilat SZ. The “continuity visit” and the hospitalist model of care. Dis Mon. 2002;48(4):267-272.

In late January, the Centers for Medicare and Medicaid Services (CMS) released the early results of two multi-year innovation projects focused on the creation of patient-centered medical homes (PCMHs).

Although PCMH models have been lauded as a way to achieve CMS’ triple aim —better quality patient care and improved health at a lower cost—little evidence currently backs up this claim. The latest reports show that PCMH interventions hold promise, but the jury is still out.

“I think, two to three years from now, we will be in a totally different position, in terms of a sound evidence base for policy,” says Mark Friedberg, MD, MPP, a practicing general internist and senior natural scientist for the RAND Corporation. “We know these very large CMS demonstrations are just starting to trickle in with year one results.”

Both the Comprehensive Primary Care (CPC) Initiative and the Multi-payer Advanced Primary Care Practice (MAPCP) are large, multi-year CMS demonstrations launched in 2012 and 2011, respectively, and the reports cover just their first 12 months. Although different in numerous ways, both projects aim to create better coordinated care that will in turn lower hospital admissions and ED visits, reduce duplications, enhance patient health through prevention, improve chronic disease management, and move away from a fee-for-service approach. They are just two of many experiments supported by the 10-year, $10 billion CMS Innovation Center.

In its first 12 months, the CPC focused on improving the care of high-risk patients in four states plus three separate regions of the U.S. It served 345,000 Medicare beneficiaries and roughly 2.5 million patients overall among nearly 500 primary care practices identified as likely to achieve meaningful results.

The evaluation, performed by policy research firm Mathematica, found that CPC cut hospital admissions by 2% and saw a 3% reduction in ED visits relative to similar practices not participating in the initiative, contributing to an overall $168 savings per Medicare beneficiary. It generated more than $70,000 in additional revenue per median practice clinician.¹

However, the Department of Health and Human Services (HHS) paid practices $240 per patient to cover the costs of establishing the medical home, including hiring nurses, improving electronic health records, and setting up 24-hour call lines. Thus, the initiative failed to offset its costs. Even so, Mathematica called the findings “promising” and “more favorable” than expected for the first year of the initiative, though it advised caution in interpreting the findings at this stage.

The MAPCP involved primary care initiatives in eight states, encompassing 3,800 providers across 700 practices; it touched 400,000 Medicare beneficiaries in its first year (today, it serves practices in just six states). Private payers and Medicaid also took part, leading to an estimated savings of $4.2 million, according to the initiative’s evaluators, RTI International and The Urban Institute.²

The demonstration realized a reduction in fee-for-service Medicare growth in Vermont and Michigan, largely resulting from lower inpatient expenditures, but did little to reduce hospitalizations, readmissions, or ED visits. Data collection and utilization were recurring challenges.

Dr. Friedberg says these first reports are akin to seeing the first few ships of the armada break the horizon. Last year, he was first author of a Journal of the American Medical Association study of a three-year PCMH intervention in Pennsylvania, Southeastern Pennsylvania’s Chronic Care Initiative, which also showed mixed results.³ He currently is part of a team evaluating the CMS Federally Qualified Health Center Advanced Primary Care Practice Demonstration, which concluded last October.

Although he has not yet seen an evaluation of a PCMH intervention involving hospitalists, Dr. Friedberg says it would be interesting to see the results of a rigorously studied pilot that involves such an evaluation. A 2012 article in The Hospitalist highlighted one project in Wisconsin and laid out ways in which hospitalists could be involved in PCMH initiatives—among them, being part of hospital admissions decision making and maintaining open lines of communication.⁴ Leaders of that project declined to comment at this time.

“The patient-centered medical home really is an outpatient strategy more than it is an inpatient strategy,” says Robert Centor, MD, MACP, an academic hospitalist at the University of Alabama Huntsville and chair of the Board of Regents of the American College of Physicians, yet he sees a role for hospitalists.

“If we start getting good results with patient-centered medical homes and more people go to the model, a relationship between the PCMH on the outpatient side and a cadre of people who know how to work the inpatient side is going to be critical to success,” Dr. Centor says.

Indeed, Dr. Friedberg says hospitalists’ involvement could be one of the “missing ingredients” that might contribute to the success of any given PCMH intervention, and he’s careful to emphasize there is no such thing as “the medical home.” Rather, there are “many medical homes,” he says.

Dr. Centor says hospitalists could serve as conduits between care inside the hospital and follow-up care, which could reduce length of stay for some patients and smooth the transition from discharge to primary care. A well-versed hospitalist with the PCMH might also assist in reducing repeat tests and procedures.

“I think it comes down to relationships more than anything else,” Dr. Centor says. “The challenge is, given all of the busyness of outpatient practice and inpatient care, how do we best communicate?”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Mathematica Policy Research. Evaluation of the Comprehensive Primary Care Initiative: first annual report. Reference number 40102.R14. Available at: http://innovation.cms.gov/Files/reports/CPCI-EvalRpt1.pdf. Accessed March 4, 2015.
2. RTI International. Evaluation of the multi-payer advanced primary care practice (MAPCP) demonstration: first annual report. RTI Project Number 0212790.005.001.001. Available at: http://innovation.cms.gov/Files/reports/MAPCP-EvalRpt1.pdf. Accessed March 4, 2015.
3. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311(8):815-825.
4. Collins T. Patients should prepare for the patient-centered medical home. The Hospitalist. July 3, 2012. Available at: http://www.the-hospitalist.org/article/hospitalists-should-prepare-for-the-patient-centered-medical-home/. Accessed March 4, 2015.

In late January, the Centers for Medicare and Medicaid Services (CMS) released the early results of two multi-year innovation projects focused on the creation of patient-centered medical homes (PCMHs).

Although PCMH models have been lauded as a way to achieve CMS’ triple aim —better quality patient care and improved health at a lower cost—little evidence currently backs up this claim. The latest reports show that PCMH interventions hold promise, but the jury is still out.

“I think, two to three years from now, we will be in a totally different position, in terms of a sound evidence base for policy,” says Mark Friedberg, MD, MPP, a practicing general internist and senior natural scientist for the RAND Corporation. “We know these very large CMS demonstrations are just starting to trickle in with year one results.”

Both the Comprehensive Primary Care (CPC) Initiative and the Multi-payer Advanced Primary Care Practice (MAPCP) are large, multi-year CMS demonstrations launched in 2012 and 2011, respectively, and the reports cover just their first 12 months. Although different in numerous ways, both projects aim to create better coordinated care that will in turn lower hospital admissions and ED visits, reduce duplications, enhance patient health through prevention, improve chronic disease management, and move away from a fee-for-service approach. They are just two of many experiments supported by the 10-year, $10 billion CMS Innovation Center.

In its first 12 months, the CPC focused on improving the care of high-risk patients in four states plus three separate regions of the U.S. It served 345,000 Medicare beneficiaries and roughly 2.5 million patients overall among nearly 500 primary care practices identified as likely to achieve meaningful results.

The evaluation, performed by policy research firm Mathematica, found that CPC cut hospital admissions by 2% and saw a 3% reduction in ED visits relative to similar practices not participating in the initiative, contributing to an overall $168 savings per Medicare beneficiary. It generated more than $70,000 in additional revenue per median practice clinician.¹

However, the Department of Health and Human Services (HHS) paid practices $240 per patient to cover the costs of establishing the medical home, including hiring nurses, improving electronic health records, and setting up 24-hour call lines. Thus, the initiative failed to offset its costs. Even so, Mathematica called the findings “promising” and “more favorable” than expected for the first year of the initiative, though it advised caution in interpreting the findings at this stage.

The MAPCP involved primary care initiatives in eight states, encompassing 3,800 providers across 700 practices; it touched 400,000 Medicare beneficiaries in its first year (today, it serves practices in just six states). Private payers and Medicaid also took part, leading to an estimated savings of $4.2 million, according to the initiative’s evaluators, RTI International and The Urban Institute.²

The demonstration realized a reduction in fee-for-service Medicare growth in Vermont and Michigan, largely resulting from lower inpatient expenditures, but did little to reduce hospitalizations, readmissions, or ED visits. Data collection and utilization were recurring challenges.

Dr. Friedberg says these first reports are akin to seeing the first few ships of the armada break the horizon. Last year, he was first author of a Journal of the American Medical Association study of a three-year PCMH intervention in Pennsylvania, Southeastern Pennsylvania’s Chronic Care Initiative, which also showed mixed results.³ He currently is part of a team evaluating the CMS Federally Qualified Health Center Advanced Primary Care Practice Demonstration, which concluded last October.

Although he has not yet seen an evaluation of a PCMH intervention involving hospitalists, Dr. Friedberg says it would be interesting to see the results of a rigorously studied pilot that involves such an evaluation. A 2012 article in The Hospitalist highlighted one project in Wisconsin and laid out ways in which hospitalists could be involved in PCMH initiatives—among them, being part of hospital admissions decision making and maintaining open lines of communication.⁴ Leaders of that project declined to comment at this time.

“The patient-centered medical home really is an outpatient strategy more than it is an inpatient strategy,” says Robert Centor, MD, MACP, an academic hospitalist at the University of Alabama Huntsville and chair of the Board of Regents of the American College of Physicians, yet he sees a role for hospitalists.

“If we start getting good results with patient-centered medical homes and more people go to the model, a relationship between the PCMH on the outpatient side and a cadre of people who know how to work the inpatient side is going to be critical to success,” Dr. Centor says.

Indeed, Dr. Friedberg says hospitalists’ involvement could be one of the “missing ingredients” that might contribute to the success of any given PCMH intervention, and he’s careful to emphasize there is no such thing as “the medical home.” Rather, there are “many medical homes,” he says.

Dr. Centor says hospitalists could serve as conduits between care inside the hospital and follow-up care, which could reduce length of stay for some patients and smooth the transition from discharge to primary care. A well-versed hospitalist with the PCMH might also assist in reducing repeat tests and procedures.

“I think it comes down to relationships more than anything else,” Dr. Centor says. “The challenge is, given all of the busyness of outpatient practice and inpatient care, how do we best communicate?”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Mathematica Policy Research. Evaluation of the Comprehensive Primary Care Initiative: first annual report. Reference number 40102.R14. Available at: http://innovation.cms.gov/Files/reports/CPCI-EvalRpt1.pdf. Accessed March 4, 2015.
2. RTI International. Evaluation of the multi-payer advanced primary care practice (MAPCP) demonstration: first annual report. RTI Project Number 0212790.005.001.001. Available at: http://innovation.cms.gov/Files/reports/MAPCP-EvalRpt1.pdf. Accessed March 4, 2015.
3. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311(8):815-825.
4. Collins T. Patients should prepare for the patient-centered medical home. The Hospitalist. July 3, 2012. Available at: http://www.the-hospitalist.org/article/hospitalists-should-prepare-for-the-patient-centered-medical-home/. Accessed March 4, 2015.

In late January, the Centers for Medicare and Medicaid Services (CMS) released the early results of two multi-year innovation projects focused on the creation of patient-centered medical homes (PCMHs).

Although PCMH models have been lauded as a way to achieve CMS’ triple aim —better quality patient care and improved health at a lower cost—little evidence currently backs up this claim. The latest reports show that PCMH interventions hold promise, but the jury is still out.

“I think, two to three years from now, we will be in a totally different position, in terms of a sound evidence base for policy,” says Mark Friedberg, MD, MPP, a practicing general internist and senior natural scientist for the RAND Corporation. “We know these very large CMS demonstrations are just starting to trickle in with year one results.”

Both the Comprehensive Primary Care (CPC) Initiative and the Multi-payer Advanced Primary Care Practice (MAPCP) are large, multi-year CMS demonstrations launched in 2012 and 2011, respectively, and the reports cover just their first 12 months. Although different in numerous ways, both projects aim to create better coordinated care that will in turn lower hospital admissions and ED visits, reduce duplications, enhance patient health through prevention, improve chronic disease management, and move away from a fee-for-service approach. They are just two of many experiments supported by the 10-year, $10 billion CMS Innovation Center.

In its first 12 months, the CPC focused on improving the care of high-risk patients in four states plus three separate regions of the U.S. It served 345,000 Medicare beneficiaries and roughly 2.5 million patients overall among nearly 500 primary care practices identified as likely to achieve meaningful results.

The evaluation, performed by policy research firm Mathematica, found that CPC cut hospital admissions by 2% and saw a 3% reduction in ED visits relative to similar practices not participating in the initiative, contributing to an overall $168 savings per Medicare beneficiary. It generated more than $70,000 in additional revenue per median practice clinician.¹

However, the Department of Health and Human Services (HHS) paid practices $240 per patient to cover the costs of establishing the medical home, including hiring nurses, improving electronic health records, and setting up 24-hour call lines. Thus, the initiative failed to offset its costs. Even so, Mathematica called the findings “promising” and “more favorable” than expected for the first year of the initiative, though it advised caution in interpreting the findings at this stage.

The MAPCP involved primary care initiatives in eight states, encompassing 3,800 providers across 700 practices; it touched 400,000 Medicare beneficiaries in its first year (today, it serves practices in just six states). Private payers and Medicaid also took part, leading to an estimated savings of $4.2 million, according to the initiative’s evaluators, RTI International and The Urban Institute.²

The demonstration realized a reduction in fee-for-service Medicare growth in Vermont and Michigan, largely resulting from lower inpatient expenditures, but did little to reduce hospitalizations, readmissions, or ED visits. Data collection and utilization were recurring challenges.

Dr. Friedberg says these first reports are akin to seeing the first few ships of the armada break the horizon. Last year, he was first author of a Journal of the American Medical Association study of a three-year PCMH intervention in Pennsylvania, Southeastern Pennsylvania’s Chronic Care Initiative, which also showed mixed results.³ He currently is part of a team evaluating the CMS Federally Qualified Health Center Advanced Primary Care Practice Demonstration, which concluded last October.

Although he has not yet seen an evaluation of a PCMH intervention involving hospitalists, Dr. Friedberg says it would be interesting to see the results of a rigorously studied pilot that involves such an evaluation. A 2012 article in The Hospitalist highlighted one project in Wisconsin and laid out ways in which hospitalists could be involved in PCMH initiatives—among them, being part of hospital admissions decision making and maintaining open lines of communication.⁴ Leaders of that project declined to comment at this time.

“The patient-centered medical home really is an outpatient strategy more than it is an inpatient strategy,” says Robert Centor, MD, MACP, an academic hospitalist at the University of Alabama Huntsville and chair of the Board of Regents of the American College of Physicians, yet he sees a role for hospitalists.

“If we start getting good results with patient-centered medical homes and more people go to the model, a relationship between the PCMH on the outpatient side and a cadre of people who know how to work the inpatient side is going to be critical to success,” Dr. Centor says.

Indeed, Dr. Friedberg says hospitalists’ involvement could be one of the “missing ingredients” that might contribute to the success of any given PCMH intervention, and he’s careful to emphasize there is no such thing as “the medical home.” Rather, there are “many medical homes,” he says.

Dr. Centor says hospitalists could serve as conduits between care inside the hospital and follow-up care, which could reduce length of stay for some patients and smooth the transition from discharge to primary care. A well-versed hospitalist with the PCMH might also assist in reducing repeat tests and procedures.

“I think it comes down to relationships more than anything else,” Dr. Centor says. “The challenge is, given all of the busyness of outpatient practice and inpatient care, how do we best communicate?”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Mathematica Policy Research. Evaluation of the Comprehensive Primary Care Initiative: first annual report. Reference number 40102.R14. Available at: http://innovation.cms.gov/Files/reports/CPCI-EvalRpt1.pdf. Accessed March 4, 2015.
2. RTI International. Evaluation of the multi-payer advanced primary care practice (MAPCP) demonstration: first annual report. RTI Project Number 0212790.005.001.001. Available at: http://innovation.cms.gov/Files/reports/MAPCP-EvalRpt1.pdf. Accessed March 4, 2015.
3. Friedberg MW, Schneider EC, Rosenthal MB, Volpp KG, Werner RM. Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. JAMA. 2014;311(8):815-825.
4. Collins T. Patients should prepare for the patient-centered medical home. The Hospitalist. July 3, 2012. Available at: http://www.the-hospitalist.org/article/hospitalists-should-prepare-for-the-patient-centered-medical-home/. Accessed March 4, 2015.

Editor’s note: first published online at shmcareercenter.org

There are many practical skills you should hone if you are interested in becoming a team leader in your hospital medicine group—among them the ability to engage others, to effectively conduct an efficient meeting, and to meet project deadlines. But more basic than that, says Jasen Gundersen, MD, MBA, CPE, SFHM, president of the Acute Care Services Division for TeamHealth in the Miami/Fort Lauderdale area, is to first ask yourself, “Why do I want to be a leader? What is it about being a leader that draws me in?”

Early career hospitalists may think leadership roles automatically yield more money and free time, Dr. Gundersen says. Actually, being a leader requires stamina and the ability to weather the ups and downs that come with the leadership role. For example, will you be able to handle situations in which your decisions make others unhappy?

Honest self-assessment is one of the most critical elements in becoming a leader, agrees Steven Deitelzweig, MD, MMM, FACP, FSVMB, RVT, VPMA, system chairman of hospital medicine and medical director of regional business development for Ochsner Health System in the greater New Orleans area. In addition to having good interpersonal skills, showing enthusiasm, and promoting your organization sincerely—what Dr. Deitelzweig labels “emotional intelligence”—prospective leaders need to be cognizant of delivering on promises.

“This is something I call a high ‘say/do’ ratio,” he explains, “and, simply put, it means that you accomplish what you say you will. At the end of the day, the only way anybody moves up is by being good at achieving results.”

If you start missing deadlines, you communicate that you are not reliable. Not all project implementation goes according to plan, of course, so when you encounter difficulties, early communication about obstacles is also key, he says.

Through SHM’s Leadership Academy, hospitalists can be trained in team management and other key leadership skills. An October 2015 session is scheduled in Austin.

Having trusted mentors is crucial, agreed both physicians, so that you can keep polishing your skill set and obtain honest feedback. These mentors should not be people to whom you directly report, and they need not be in the healthcare industry.

In fact, Dr. Gundersen says he’s known mentors for years “who have not been in the same specialty or even the same field, but who give me guidance and have helped make me into the leader I am.”

How do you assert your desire to be a leader? Dr. Deitelzweig suggests making your aspirations clear to your own group leaders. The annual review is an excellent juncture at which to discuss this, he says.

If you do not yet have project management or communications experience, ask your leaders whether they are familiar with training to help you develop those skills. In the current healthcare environment, the Affordable Care Act and reimbursement regulations mean that change will continue to be part of the leadership challenge.

“If you really want to be a leader,” Dr. Deitelzweig says, “you cannot be a naysayer. Make change work for you, look at it as an opportunity for you to innovate, and then show how valuable you can be.”

Gretchen Henkel is a freelance writer in California.

Editor’s note: first published online at shmcareercenter.org

There are many practical skills you should hone if you are interested in becoming a team leader in your hospital medicine group—among them the ability to engage others, to effectively conduct an efficient meeting, and to meet project deadlines. But more basic than that, says Jasen Gundersen, MD, MBA, CPE, SFHM, president of the Acute Care Services Division for TeamHealth in the Miami/Fort Lauderdale area, is to first ask yourself, “Why do I want to be a leader? What is it about being a leader that draws me in?”

Early career hospitalists may think leadership roles automatically yield more money and free time, Dr. Gundersen says. Actually, being a leader requires stamina and the ability to weather the ups and downs that come with the leadership role. For example, will you be able to handle situations in which your decisions make others unhappy?

Honest self-assessment is one of the most critical elements in becoming a leader, agrees Steven Deitelzweig, MD, MMM, FACP, FSVMB, RVT, VPMA, system chairman of hospital medicine and medical director of regional business development for Ochsner Health System in the greater New Orleans area. In addition to having good interpersonal skills, showing enthusiasm, and promoting your organization sincerely—what Dr. Deitelzweig labels “emotional intelligence”—prospective leaders need to be cognizant of delivering on promises.

“This is something I call a high ‘say/do’ ratio,” he explains, “and, simply put, it means that you accomplish what you say you will. At the end of the day, the only way anybody moves up is by being good at achieving results.”

If you start missing deadlines, you communicate that you are not reliable. Not all project implementation goes according to plan, of course, so when you encounter difficulties, early communication about obstacles is also key, he says.

Through SHM’s Leadership Academy, hospitalists can be trained in team management and other key leadership skills. An October 2015 session is scheduled in Austin.

Having trusted mentors is crucial, agreed both physicians, so that you can keep polishing your skill set and obtain honest feedback. These mentors should not be people to whom you directly report, and they need not be in the healthcare industry.

In fact, Dr. Gundersen says he’s known mentors for years “who have not been in the same specialty or even the same field, but who give me guidance and have helped make me into the leader I am.”

How do you assert your desire to be a leader? Dr. Deitelzweig suggests making your aspirations clear to your own group leaders. The annual review is an excellent juncture at which to discuss this, he says.

If you do not yet have project management or communications experience, ask your leaders whether they are familiar with training to help you develop those skills. In the current healthcare environment, the Affordable Care Act and reimbursement regulations mean that change will continue to be part of the leadership challenge.

“If you really want to be a leader,” Dr. Deitelzweig says, “you cannot be a naysayer. Make change work for you, look at it as an opportunity for you to innovate, and then show how valuable you can be.”

Gretchen Henkel is a freelance writer in California.

Editor’s note: first published online at shmcareercenter.org

There are many practical skills you should hone if you are interested in becoming a team leader in your hospital medicine group—among them the ability to engage others, to effectively conduct an efficient meeting, and to meet project deadlines. But more basic than that, says Jasen Gundersen, MD, MBA, CPE, SFHM, president of the Acute Care Services Division for TeamHealth in the Miami/Fort Lauderdale area, is to first ask yourself, “Why do I want to be a leader? What is it about being a leader that draws me in?”

Early career hospitalists may think leadership roles automatically yield more money and free time, Dr. Gundersen says. Actually, being a leader requires stamina and the ability to weather the ups and downs that come with the leadership role. For example, will you be able to handle situations in which your decisions make others unhappy?

Honest self-assessment is one of the most critical elements in becoming a leader, agrees Steven Deitelzweig, MD, MMM, FACP, FSVMB, RVT, VPMA, system chairman of hospital medicine and medical director of regional business development for Ochsner Health System in the greater New Orleans area. In addition to having good interpersonal skills, showing enthusiasm, and promoting your organization sincerely—what Dr. Deitelzweig labels “emotional intelligence”—prospective leaders need to be cognizant of delivering on promises.

“This is something I call a high ‘say/do’ ratio,” he explains, “and, simply put, it means that you accomplish what you say you will. At the end of the day, the only way anybody moves up is by being good at achieving results.”

If you start missing deadlines, you communicate that you are not reliable. Not all project implementation goes according to plan, of course, so when you encounter difficulties, early communication about obstacles is also key, he says.

Through SHM’s Leadership Academy, hospitalists can be trained in team management and other key leadership skills. An October 2015 session is scheduled in Austin.

Having trusted mentors is crucial, agreed both physicians, so that you can keep polishing your skill set and obtain honest feedback. These mentors should not be people to whom you directly report, and they need not be in the healthcare industry.

In fact, Dr. Gundersen says he’s known mentors for years “who have not been in the same specialty or even the same field, but who give me guidance and have helped make me into the leader I am.”

How do you assert your desire to be a leader? Dr. Deitelzweig suggests making your aspirations clear to your own group leaders. The annual review is an excellent juncture at which to discuss this, he says.

If you do not yet have project management or communications experience, ask your leaders whether they are familiar with training to help you develop those skills. In the current healthcare environment, the Affordable Care Act and reimbursement regulations mean that change will continue to be part of the leadership challenge.

“If you really want to be a leader,” Dr. Deitelzweig says, “you cannot be a naysayer. Make change work for you, look at it as an opportunity for you to innovate, and then show how valuable you can be.”

Gretchen Henkel is a freelance writer in California.

Hospitalists often are tasked with coordinating and overseeing patient care throughout a hospitalization. Depending on the care model and the availability of varying specialists, a patient could see several specialists throughout the stay, and even during a single day. A recurring issue for many hospitalists is justifying the medical necessity of their services, because payers do not want to reimburse overlapping care (i.e., multiple providers caring for the same patient problem) when more than one physician provides care on the same service date.

Payers often consider two key principles before reimbursing multiple visits on the same date:¹

• Does the patient’s condition warrant the services of more than one physician?
• Are the individual services provided by each physician reasonable and necessary?

Consider the following example: A 65-year-old female patient is admitted with a hip fracture (820.8) after slipping on the ice outside her home. The patient also has hypertension (401.1) and type II diabetes (250.00). The surgeon manages the patient’s peri-operative course for the fracture, while the hospitalist manages the patient’s medical issues.

Payers must be sure that the services of one physician do not duplicate those provided by another.1 For the above scenario, it is imperative that the hospitalist understand which services are considered the surgeon’s responsibility. The global surgical package includes payment for the surgical procedure and the completion of its corresponding facility-required paperwork (e.g. pre-operative history and physical exam, operative consent forms, pre-operative orders), in addition to the following services:²

• Pre-operative visits after making the decision for surgery beginning one day prior to surgery;
• All additional post-operative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Post-operative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes, local incisional care, removal of cutaneous sutures and staples, line removals, changes and removal of tracheostomy tubes, and discharge services; and
• Post-operative pain management provided by the surgeon.

Another physician who performs any component of the global package will not receive separate payment unless the surgeon is willing to forego a portion of the payment. For example, a hospitalist admits a patient who has no other identifiable medical conditions aside from the problem prompting surgery. The hospitalist’s role may be dictated by facility policy—quality of care or risk reduction, for example—and administrative requirements (history and physical exam, discharge services, coordination of care) rather than what a payer would perceive as necessary “medical” management. Similarly, if the hospitalist’s post-op care is limited to ordering routine post-op labs or maintaining appropriate pain management, the hospitalist’s service will likely be denied as incidental to the surgical package.

Remember, if the hospitalist’s claim is submitted and paid, it doesn’t mean that the payer won’t retract the payment upon review if an erroneous payment is suspected. A payer review may be triggered when the diagnosis listed on the hospitalist’s claim matches the diagnosis listed on the surgeon’s claim (e.g. 820.8). If too many claims are considered “not medically necessary” due to overlapping care, hospitalists may need to negotiate other terms of payment with the facility to recoup unpaid time and effort when involved in this type of care.

When more than one medical condition exists and several physicians participate in the patient’s care, medical necessity is easily established for each physician. Each physician manages the condition related to his/her expertise. In the above example, the surgeon cares for the patient’s fracture, while the hospitalist oversees diabetes and hypertension management. Service distinction is crucial during the claim submission process. The hospitalist should report a subsequent hospital care code (99231-99233) with a primary diagnosis corresponding to his/her specialty-related care (i.e., 9923x with 250.00, 401.1).³

When more specialists are involved, claim submission becomes more complex. A cardiologist who was also involved in patient management would report his or her service using 401.1. When a different primary diagnosis is assigned to the visit code to indicate the reason for each physician’s involvement, all claims are more likely to be paid.⁴ As long as the hospitalist maintains care over one of the patients’ conditions, concurrent care is justified.

Because these physicians are in different specialties and different provider groups, most payers do not require the modifier 25 (separately identifiable evaluation/management [E/M] service on the same day as a procedure or other service) with the visit code; however, some managed care payers may have a general claim edit that pays the first claim and denies the second unless modifier 25 is appended to the concurrent E/M visit code (i.e., 99232-25) as an attestation that the service is distinct from any other provider’s service that day, despite claim submission under different tax identification numbers. This may not be identified until the claim is rejected or denied. If appropriate modifier use does not yield payment, appeal the denied concurrent care claims with supporting documentation from each physician visit, if possible. This demonstrates each physician’s contribution to care.

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. Medicare Benefit Policy Manual: Chapter 15—Covered Medical and Other Health Services. Section 30.E. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed March 5, 2015.
2. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 40.A. Available at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed March 5, 2015.
3. American Medical Association. Current Procedural Terminology 2015 Professional Edition. Chicago: American Medical Association Press; 2014.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 30.6.9.C. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2015.
5. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 30.6.5. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2015.
6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 26—Completing and Processing Form CMS-1500 Data Set. Section 10.8.2. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf. Accessed March 5, 2015.

Hospitalists often are tasked with coordinating and overseeing patient care throughout a hospitalization. Depending on the care model and the availability of varying specialists, a patient could see several specialists throughout the stay, and even during a single day. A recurring issue for many hospitalists is justifying the medical necessity of their services, because payers do not want to reimburse overlapping care (i.e., multiple providers caring for the same patient problem) when more than one physician provides care on the same service date.

Payers often consider two key principles before reimbursing multiple visits on the same date:¹

• Does the patient’s condition warrant the services of more than one physician?
• Are the individual services provided by each physician reasonable and necessary?

Consider the following example: A 65-year-old female patient is admitted with a hip fracture (820.8) after slipping on the ice outside her home. The patient also has hypertension (401.1) and type II diabetes (250.00). The surgeon manages the patient’s peri-operative course for the fracture, while the hospitalist manages the patient’s medical issues.

Payers must be sure that the services of one physician do not duplicate those provided by another.1 For the above scenario, it is imperative that the hospitalist understand which services are considered the surgeon’s responsibility. The global surgical package includes payment for the surgical procedure and the completion of its corresponding facility-required paperwork (e.g. pre-operative history and physical exam, operative consent forms, pre-operative orders), in addition to the following services:²

• Pre-operative visits after making the decision for surgery beginning one day prior to surgery;
• All additional post-operative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Post-operative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes, local incisional care, removal of cutaneous sutures and staples, line removals, changes and removal of tracheostomy tubes, and discharge services; and
• Post-operative pain management provided by the surgeon.

Another physician who performs any component of the global package will not receive separate payment unless the surgeon is willing to forego a portion of the payment. For example, a hospitalist admits a patient who has no other identifiable medical conditions aside from the problem prompting surgery. The hospitalist’s role may be dictated by facility policy—quality of care or risk reduction, for example—and administrative requirements (history and physical exam, discharge services, coordination of care) rather than what a payer would perceive as necessary “medical” management. Similarly, if the hospitalist’s post-op care is limited to ordering routine post-op labs or maintaining appropriate pain management, the hospitalist’s service will likely be denied as incidental to the surgical package.

Remember, if the hospitalist’s claim is submitted and paid, it doesn’t mean that the payer won’t retract the payment upon review if an erroneous payment is suspected. A payer review may be triggered when the diagnosis listed on the hospitalist’s claim matches the diagnosis listed on the surgeon’s claim (e.g. 820.8). If too many claims are considered “not medically necessary” due to overlapping care, hospitalists may need to negotiate other terms of payment with the facility to recoup unpaid time and effort when involved in this type of care.

When more than one medical condition exists and several physicians participate in the patient’s care, medical necessity is easily established for each physician. Each physician manages the condition related to his/her expertise. In the above example, the surgeon cares for the patient’s fracture, while the hospitalist oversees diabetes and hypertension management. Service distinction is crucial during the claim submission process. The hospitalist should report a subsequent hospital care code (99231-99233) with a primary diagnosis corresponding to his/her specialty-related care (i.e., 9923x with 250.00, 401.1).³

When more specialists are involved, claim submission becomes more complex. A cardiologist who was also involved in patient management would report his or her service using 401.1. When a different primary diagnosis is assigned to the visit code to indicate the reason for each physician’s involvement, all claims are more likely to be paid.⁴ As long as the hospitalist maintains care over one of the patients’ conditions, concurrent care is justified.

Because these physicians are in different specialties and different provider groups, most payers do not require the modifier 25 (separately identifiable evaluation/management [E/M] service on the same day as a procedure or other service) with the visit code; however, some managed care payers may have a general claim edit that pays the first claim and denies the second unless modifier 25 is appended to the concurrent E/M visit code (i.e., 99232-25) as an attestation that the service is distinct from any other provider’s service that day, despite claim submission under different tax identification numbers. This may not be identified until the claim is rejected or denied. If appropriate modifier use does not yield payment, appeal the denied concurrent care claims with supporting documentation from each physician visit, if possible. This demonstrates each physician’s contribution to care.

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. Medicare Benefit Policy Manual: Chapter 15—Covered Medical and Other Health Services. Section 30.E. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed March 5, 2015.
2. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 40.A. Available at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed March 5, 2015.
3. American Medical Association. Current Procedural Terminology 2015 Professional Edition. Chicago: American Medical Association Press; 2014.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 30.6.9.C. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2015.
5. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 30.6.5. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2015.
6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 26—Completing and Processing Form CMS-1500 Data Set. Section 10.8.2. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf. Accessed March 5, 2015.

Hospitalists often are tasked with coordinating and overseeing patient care throughout a hospitalization. Depending on the care model and the availability of varying specialists, a patient could see several specialists throughout the stay, and even during a single day. A recurring issue for many hospitalists is justifying the medical necessity of their services, because payers do not want to reimburse overlapping care (i.e., multiple providers caring for the same patient problem) when more than one physician provides care on the same service date.

Payers often consider two key principles before reimbursing multiple visits on the same date:¹

• Does the patient’s condition warrant the services of more than one physician?
• Are the individual services provided by each physician reasonable and necessary?

Consider the following example: A 65-year-old female patient is admitted with a hip fracture (820.8) after slipping on the ice outside her home. The patient also has hypertension (401.1) and type II diabetes (250.00). The surgeon manages the patient’s peri-operative course for the fracture, while the hospitalist manages the patient’s medical issues.

Payers must be sure that the services of one physician do not duplicate those provided by another.1 For the above scenario, it is imperative that the hospitalist understand which services are considered the surgeon’s responsibility. The global surgical package includes payment for the surgical procedure and the completion of its corresponding facility-required paperwork (e.g. pre-operative history and physical exam, operative consent forms, pre-operative orders), in addition to the following services:²

• Pre-operative visits after making the decision for surgery beginning one day prior to surgery;
• All additional post-operative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Post-operative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes, local incisional care, removal of cutaneous sutures and staples, line removals, changes and removal of tracheostomy tubes, and discharge services; and
• Post-operative pain management provided by the surgeon.

Another physician who performs any component of the global package will not receive separate payment unless the surgeon is willing to forego a portion of the payment. For example, a hospitalist admits a patient who has no other identifiable medical conditions aside from the problem prompting surgery. The hospitalist’s role may be dictated by facility policy—quality of care or risk reduction, for example—and administrative requirements (history and physical exam, discharge services, coordination of care) rather than what a payer would perceive as necessary “medical” management. Similarly, if the hospitalist’s post-op care is limited to ordering routine post-op labs or maintaining appropriate pain management, the hospitalist’s service will likely be denied as incidental to the surgical package.

Remember, if the hospitalist’s claim is submitted and paid, it doesn’t mean that the payer won’t retract the payment upon review if an erroneous payment is suspected. A payer review may be triggered when the diagnosis listed on the hospitalist’s claim matches the diagnosis listed on the surgeon’s claim (e.g. 820.8). If too many claims are considered “not medically necessary” due to overlapping care, hospitalists may need to negotiate other terms of payment with the facility to recoup unpaid time and effort when involved in this type of care.

When more than one medical condition exists and several physicians participate in the patient’s care, medical necessity is easily established for each physician. Each physician manages the condition related to his/her expertise. In the above example, the surgeon cares for the patient’s fracture, while the hospitalist oversees diabetes and hypertension management. Service distinction is crucial during the claim submission process. The hospitalist should report a subsequent hospital care code (99231-99233) with a primary diagnosis corresponding to his/her specialty-related care (i.e., 9923x with 250.00, 401.1).³

When more specialists are involved, claim submission becomes more complex. A cardiologist who was also involved in patient management would report his or her service using 401.1. When a different primary diagnosis is assigned to the visit code to indicate the reason for each physician’s involvement, all claims are more likely to be paid.⁴ As long as the hospitalist maintains care over one of the patients’ conditions, concurrent care is justified.

Because these physicians are in different specialties and different provider groups, most payers do not require the modifier 25 (separately identifiable evaluation/management [E/M] service on the same day as a procedure or other service) with the visit code; however, some managed care payers may have a general claim edit that pays the first claim and denies the second unless modifier 25 is appended to the concurrent E/M visit code (i.e., 99232-25) as an attestation that the service is distinct from any other provider’s service that day, despite claim submission under different tax identification numbers. This may not be identified until the claim is rejected or denied. If appropriate modifier use does not yield payment, appeal the denied concurrent care claims with supporting documentation from each physician visit, if possible. This demonstrates each physician’s contribution to care.

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. Medicare Benefit Policy Manual: Chapter 15—Covered Medical and Other Health Services. Section 30.E. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed March 5, 2015.
2. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 40.A. Available at: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed March 5, 2015.
3. American Medical Association. Current Procedural Terminology 2015 Professional Edition. Chicago: American Medical Association Press; 2014.
4. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 30.6.9.C. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2015.
5. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12—Physicians/Nonphysician Practitioners. Section 30.6.5. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed March 5, 2015.
6. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 26—Completing and Processing Form CMS-1500 Data Set. Section 10.8.2. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf. Accessed March 5, 2015.

Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?

Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.

Study design: Retrospective cohort study.

Setting: London Health Sciences Centre, Ontario, Canada.

Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.

There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.

The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.

Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.

Citation: Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015;125(6):924-929.

Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?

Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.

Study design: Retrospective cohort study.

Setting: London Health Sciences Centre, Ontario, Canada.

Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.

There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.

The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.

Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.

Citation: Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015;125(6):924-929.

Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?

Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.

Study design: Retrospective cohort study.

Setting: London Health Sciences Centre, Ontario, Canada.

Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.

There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.

The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.

Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.

Citation: Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015;125(6):924-929.

Clinical question: Does the presence of a rapid response team (RRT) affect the perception of resident education and autonomy?

Background: Studies on the perception of RRTs, which can generally be activated by any concerned staff member, have been primarily limited to nurses. No studies to date have evaluated resident perception of the effects of RRTs on education or autonomy.

Study design: Survey study measure on a five-point Likert scale.

Setting: Moffitt-Long Hospital, a 600-bed acute care hospital and tertiary academic medical center of the University of California San Francisco.

Synopsis: Among 342 potential respondents, 246 surveys were completed, 10 of which were excluded due a lack of experience with RRTs. Overall, 78% of respondents felt that working with RRTs creates a valuable educational experience, though this was seen more commonly in the responses of medical residents (83.2%) than in those of surgical residents (70.4%). There was no significant difference between interns (82.9%) and upper-level residents (77.3%).

Additionally, 75.8% of respondents did not feel that the presence of an RRT decreased resident autonomy, and there was no statistically significant difference between the responses of interns (77.8%) and upper-level residents (76.8%), or between those of medical (79.9%) and surgical (71.2%) residents.

The survey design increases the risk of response bias, and the single-site nature limits generalizability. Additionally, no objective measurements of education or autonomy were evaluated.

Bottom line: The presence of RRTs is perceived as having educational value and is not perceived by residents as reducing resident autonomy.

Citation: Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med. 2015;10(1):8-12.

Clinical question: Does the presence of a rapid response team (RRT) affect the perception of resident education and autonomy?

Background: Studies on the perception of RRTs, which can generally be activated by any concerned staff member, have been primarily limited to nurses. No studies to date have evaluated resident perception of the effects of RRTs on education or autonomy.

Study design: Survey study measure on a five-point Likert scale.

Setting: Moffitt-Long Hospital, a 600-bed acute care hospital and tertiary academic medical center of the University of California San Francisco.

Synopsis: Among 342 potential respondents, 246 surveys were completed, 10 of which were excluded due a lack of experience with RRTs. Overall, 78% of respondents felt that working with RRTs creates a valuable educational experience, though this was seen more commonly in the responses of medical residents (83.2%) than in those of surgical residents (70.4%). There was no significant difference between interns (82.9%) and upper-level residents (77.3%).

Additionally, 75.8% of respondents did not feel that the presence of an RRT decreased resident autonomy, and there was no statistically significant difference between the responses of interns (77.8%) and upper-level residents (76.8%), or between those of medical (79.9%) and surgical (71.2%) residents.

The survey design increases the risk of response bias, and the single-site nature limits generalizability. Additionally, no objective measurements of education or autonomy were evaluated.

Bottom line: The presence of RRTs is perceived as having educational value and is not perceived by residents as reducing resident autonomy.

Citation: Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med. 2015;10(1):8-12.

Clinical question: Does the presence of a rapid response team (RRT) affect the perception of resident education and autonomy?

Background: Studies on the perception of RRTs, which can generally be activated by any concerned staff member, have been primarily limited to nurses. No studies to date have evaluated resident perception of the effects of RRTs on education or autonomy.

Study design: Survey study measure on a five-point Likert scale.

Setting: Moffitt-Long Hospital, a 600-bed acute care hospital and tertiary academic medical center of the University of California San Francisco.

Synopsis: Among 342 potential respondents, 246 surveys were completed, 10 of which were excluded due a lack of experience with RRTs. Overall, 78% of respondents felt that working with RRTs creates a valuable educational experience, though this was seen more commonly in the responses of medical residents (83.2%) than in those of surgical residents (70.4%). There was no significant difference between interns (82.9%) and upper-level residents (77.3%).

Additionally, 75.8% of respondents did not feel that the presence of an RRT decreased resident autonomy, and there was no statistically significant difference between the responses of interns (77.8%) and upper-level residents (76.8%), or between those of medical (79.9%) and surgical (71.2%) residents.

The survey design increases the risk of response bias, and the single-site nature limits generalizability. Additionally, no objective measurements of education or autonomy were evaluated.

Bottom line: The presence of RRTs is perceived as having educational value and is not perceived by residents as reducing resident autonomy.

Citation: Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med. 2015;10(1):8-12.

Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?

Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.

Study design: Retrospective analysis.

Setting: Academic hospitalists at a tertiary care medical center.

Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).

This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.

Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.

Citation: Michtalik HJ, Carolan HT, Haut ER, et al. Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis. J Hosp Med. 2015;10(3):172-178.

Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?

Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.

Study design: Retrospective analysis.

Setting: Academic hospitalists at a tertiary care medical center.

Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).

This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.

Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.

Citation: Michtalik HJ, Carolan HT, Haut ER, et al. Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis. J Hosp Med. 2015;10(3):172-178.

Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?

Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.

Study design: Retrospective analysis.

Setting: Academic hospitalists at a tertiary care medical center.

Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).

This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.

Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.

Citation: Michtalik HJ, Carolan HT, Haut ER, et al. Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis. J Hosp Med. 2015;10(3):172-178.

Clinical question: Does implementing a patient verification dialog that appears at the beginning of each ordering session, accompanied by a 2.5-second delay, decrease wrong-patient orders?

Background: Computerized provider order entry (CPOE) is known to increase the rate of wrong-patient order entry and, although the rate in the ED has not been well characterized, CPOE wrong-patient order entry has been known to lead to fatalities in the emergency setting.

Study design: A parallel-controlled, experimental, before-after design.

Setting: Five teaching hospital EDs were included in New York City: two adult EDs, two pediatric EDs, and a combined ED, all totaling 250,000 annual visits.

Synopsis: The EDs in this study implemented a patient verification module into their Allscripts system. This verification included three identifiers: full name, birth date, and medical record number. A 2.5-second delay in ability to close the alert was implemented. All patients in the ED rooms were included in the analysis. The primary outcome was intercepted wrong-patient orders, as measured by number of retract and re-order events.

A baseline data set over four months was compared to immediate post-intervention data, as well as data two years post-intervention, with 30% and 25% reductions in the rate of wrong-patient orders, respectively. Of all retractions, 41% were for diagnostic procedures, 21% for medications, and 38% were nursing and miscellaneous orders. The majority of orders were placed by resident physicians (51%), followed by attending physicians (34%), physician assistants (12%), and others (3%).

This method of observation is limited to identified and corrected wrong-patient orders.

Bottom line: Implementing a patient verification alert can significantly decrease the number of order retractions and re-orders due to wrong-patient order entry in the ED setting.

Citation: Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider order entry system [published online ahead of print December 17, 2014]. Ann Emerg Med.

Clinical question: Does implementing a patient verification dialog that appears at the beginning of each ordering session, accompanied by a 2.5-second delay, decrease wrong-patient orders?

Background: Computerized provider order entry (CPOE) is known to increase the rate of wrong-patient order entry and, although the rate in the ED has not been well characterized, CPOE wrong-patient order entry has been known to lead to fatalities in the emergency setting.

Study design: A parallel-controlled, experimental, before-after design.

Setting: Five teaching hospital EDs were included in New York City: two adult EDs, two pediatric EDs, and a combined ED, all totaling 250,000 annual visits.

Synopsis: The EDs in this study implemented a patient verification module into their Allscripts system. This verification included three identifiers: full name, birth date, and medical record number. A 2.5-second delay in ability to close the alert was implemented. All patients in the ED rooms were included in the analysis. The primary outcome was intercepted wrong-patient orders, as measured by number of retract and re-order events.

A baseline data set over four months was compared to immediate post-intervention data, as well as data two years post-intervention, with 30% and 25% reductions in the rate of wrong-patient orders, respectively. Of all retractions, 41% were for diagnostic procedures, 21% for medications, and 38% were nursing and miscellaneous orders. The majority of orders were placed by resident physicians (51%), followed by attending physicians (34%), physician assistants (12%), and others (3%).

This method of observation is limited to identified and corrected wrong-patient orders.

Bottom line: Implementing a patient verification alert can significantly decrease the number of order retractions and re-orders due to wrong-patient order entry in the ED setting.

Citation: Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider order entry system [published online ahead of print December 17, 2014]. Ann Emerg Med.

Clinical question: Does implementing a patient verification dialog that appears at the beginning of each ordering session, accompanied by a 2.5-second delay, decrease wrong-patient orders?

Background: Computerized provider order entry (CPOE) is known to increase the rate of wrong-patient order entry and, although the rate in the ED has not been well characterized, CPOE wrong-patient order entry has been known to lead to fatalities in the emergency setting.

Study design: A parallel-controlled, experimental, before-after design.

Setting: Five teaching hospital EDs were included in New York City: two adult EDs, two pediatric EDs, and a combined ED, all totaling 250,000 annual visits.

Synopsis: The EDs in this study implemented a patient verification module into their Allscripts system. This verification included three identifiers: full name, birth date, and medical record number. A 2.5-second delay in ability to close the alert was implemented. All patients in the ED rooms were included in the analysis. The primary outcome was intercepted wrong-patient orders, as measured by number of retract and re-order events.

A baseline data set over four months was compared to immediate post-intervention data, as well as data two years post-intervention, with 30% and 25% reductions in the rate of wrong-patient orders, respectively. Of all retractions, 41% were for diagnostic procedures, 21% for medications, and 38% were nursing and miscellaneous orders. The majority of orders were placed by resident physicians (51%), followed by attending physicians (34%), physician assistants (12%), and others (3%).

This method of observation is limited to identified and corrected wrong-patient orders.

Bottom line: Implementing a patient verification alert can significantly decrease the number of order retractions and re-orders due to wrong-patient order entry in the ED setting.

Citation: Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider order entry system [published online ahead of print December 17, 2014]. Ann Emerg Med.

Clinical question: What is the incidence of transfusion-associated circulatory overload (TACO) as it relates to specific characteristics of patients and transfusion situations?

Background: TACO is the second-leading cause of transfusion-related fatalities; however, the epidemiology of TACO is centered mostly on patients in the ICU, and the epidemiology for noncardiac surgical patients is not well characterized. This might result in suboptimal care delivery and unfavorable outcomes in peri-operative patients.

Study design: Retrospective cohort study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Using an electronic algorithm, 2,162 and 1,908 patients in 2004 and 2011, respectively, were screened for TACO if they received intra-operative transfusions during noncardiac surgery with general anesthesia. Analyses evaluated associations between patient and transfusion characteristics with TACO rates. Patients with TACO were compared to complication-free transfused counterparts.

The incidence of TACO increased significantly with the volume of blood product transfused, advanced age, and total intra-operative fluid balance. Mixed blood products had highest incidence of TACO, followed by fresh frozen plasma. Vascular, transplant, and thoracic surgeries had the highest, and obstetric and gynecologic surgeries the lowest TACO rates. Patients with TACO, compared with their counterparts, had a longer ICU and hospital length of stay.

The study population is derived from a single tertiary care referral center and confounded by referral bias, and, therefore, not easily generalizable. Also, results cannot be generalized to nongeneral anesthesia patients.

Although associations were noted between certain characteristics and the development of TACO, more robust and definitive evaluations of TACO risk factors are needed, as many rates were not adjusted for confounding factors.

Bottom line: Understanding characteristics of at-risk patients may facilitate improved decision making regarding transfusion strategies for peri-operative noncardiac surgical patients.

Citation: Clifford L, Jia Q, Yadav H, et al. Characterizing the epidemiology of perioperative transfusion-associated circulatory overload. Anesthesiology. 2015;122(1):21-28.

Clinical question: What is the incidence of transfusion-associated circulatory overload (TACO) as it relates to specific characteristics of patients and transfusion situations?

Background: TACO is the second-leading cause of transfusion-related fatalities; however, the epidemiology of TACO is centered mostly on patients in the ICU, and the epidemiology for noncardiac surgical patients is not well characterized. This might result in suboptimal care delivery and unfavorable outcomes in peri-operative patients.

Study design: Retrospective cohort study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Using an electronic algorithm, 2,162 and 1,908 patients in 2004 and 2011, respectively, were screened for TACO if they received intra-operative transfusions during noncardiac surgery with general anesthesia. Analyses evaluated associations between patient and transfusion characteristics with TACO rates. Patients with TACO were compared to complication-free transfused counterparts.

The incidence of TACO increased significantly with the volume of blood product transfused, advanced age, and total intra-operative fluid balance. Mixed blood products had highest incidence of TACO, followed by fresh frozen plasma. Vascular, transplant, and thoracic surgeries had the highest, and obstetric and gynecologic surgeries the lowest TACO rates. Patients with TACO, compared with their counterparts, had a longer ICU and hospital length of stay.

The study population is derived from a single tertiary care referral center and confounded by referral bias, and, therefore, not easily generalizable. Also, results cannot be generalized to nongeneral anesthesia patients.

Although associations were noted between certain characteristics and the development of TACO, more robust and definitive evaluations of TACO risk factors are needed, as many rates were not adjusted for confounding factors.

Bottom line: Understanding characteristics of at-risk patients may facilitate improved decision making regarding transfusion strategies for peri-operative noncardiac surgical patients.

Citation: Clifford L, Jia Q, Yadav H, et al. Characterizing the epidemiology of perioperative transfusion-associated circulatory overload. Anesthesiology. 2015;122(1):21-28.

Clinical question: What is the incidence of transfusion-associated circulatory overload (TACO) as it relates to specific characteristics of patients and transfusion situations?

Background: TACO is the second-leading cause of transfusion-related fatalities; however, the epidemiology of TACO is centered mostly on patients in the ICU, and the epidemiology for noncardiac surgical patients is not well characterized. This might result in suboptimal care delivery and unfavorable outcomes in peri-operative patients.

Study design: Retrospective cohort study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Using an electronic algorithm, 2,162 and 1,908 patients in 2004 and 2011, respectively, were screened for TACO if they received intra-operative transfusions during noncardiac surgery with general anesthesia. Analyses evaluated associations between patient and transfusion characteristics with TACO rates. Patients with TACO were compared to complication-free transfused counterparts.

The incidence of TACO increased significantly with the volume of blood product transfused, advanced age, and total intra-operative fluid balance. Mixed blood products had highest incidence of TACO, followed by fresh frozen plasma. Vascular, transplant, and thoracic surgeries had the highest, and obstetric and gynecologic surgeries the lowest TACO rates. Patients with TACO, compared with their counterparts, had a longer ICU and hospital length of stay.

The study population is derived from a single tertiary care referral center and confounded by referral bias, and, therefore, not easily generalizable. Also, results cannot be generalized to nongeneral anesthesia patients.

Although associations were noted between certain characteristics and the development of TACO, more robust and definitive evaluations of TACO risk factors are needed, as many rates were not adjusted for confounding factors.

Bottom line: Understanding characteristics of at-risk patients may facilitate improved decision making regarding transfusion strategies for peri-operative noncardiac surgical patients.

Citation: Clifford L, Jia Q, Yadav H, et al. Characterizing the epidemiology of perioperative transfusion-associated circulatory overload. Anesthesiology. 2015;122(1):21-28.

Clinical question: What characteristics in patients with acute encephalitis portend a worse prognosis?

Background: Acute encephalitis is a serious neurologic disease with high levels of associated morbidity, mortality, and cost of care. Yet, little is known about the factors that affect the outcome of patients with encephalitis.

Study design: Retrospective chart review of all consecutive patients diagnosed with acute encephalitis.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: A retrospective chart review revealed 198 patients with encephalitis, grouped into viral, autoimmune, or unknown/other encephalitis categories, with mortality rates of 8%, 12%, and 5%, respectively. Researchers calculated a modified Rankin Scale score (mRS) on factors associated with good (mRS=0-2) or poor (mRS=3-6) outcome after one year. Factors associated with poor outcome included age 65 or older, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia. Unlike some previous studies, MRI findings and seizure activity did not portend a poor outcome. For viral encephalitis, cerebrospinal fluid polymorphonuclear cell count was also strongly associated with poor outcome.

This is one of the first studies to evaluate functional outcome or distant follow-up; however, it has inherent biases related to the retrospective design, and the results are not necessarily generalizable to all hospitals; there might be an underlying referral bias, given the fact that one third of the patients were referred to the center for further evaluation.

This study does suggest aggressive treatment should be pursued, even in patients with severe presentation, given the possibility of favorable recovery.

Bottom line: Advanced age, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia portend a worse outcome for patients with acute encephalitis.

Citation: Singh TD, Fugate JE, Rabinstein AA. The spectrum of acute encephalitis: causes, management, and predictors of outcome. Neurology. 2015;84(4):359-366.

Clinical question: What characteristics in patients with acute encephalitis portend a worse prognosis?

Background: Acute encephalitis is a serious neurologic disease with high levels of associated morbidity, mortality, and cost of care. Yet, little is known about the factors that affect the outcome of patients with encephalitis.

Study design: Retrospective chart review of all consecutive patients diagnosed with acute encephalitis.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: A retrospective chart review revealed 198 patients with encephalitis, grouped into viral, autoimmune, or unknown/other encephalitis categories, with mortality rates of 8%, 12%, and 5%, respectively. Researchers calculated a modified Rankin Scale score (mRS) on factors associated with good (mRS=0-2) or poor (mRS=3-6) outcome after one year. Factors associated with poor outcome included age 65 or older, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia. Unlike some previous studies, MRI findings and seizure activity did not portend a poor outcome. For viral encephalitis, cerebrospinal fluid polymorphonuclear cell count was also strongly associated with poor outcome.

This is one of the first studies to evaluate functional outcome or distant follow-up; however, it has inherent biases related to the retrospective design, and the results are not necessarily generalizable to all hospitals; there might be an underlying referral bias, given the fact that one third of the patients were referred to the center for further evaluation.

This study does suggest aggressive treatment should be pursued, even in patients with severe presentation, given the possibility of favorable recovery.

Bottom line: Advanced age, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia portend a worse outcome for patients with acute encephalitis.

Citation: Singh TD, Fugate JE, Rabinstein AA. The spectrum of acute encephalitis: causes, management, and predictors of outcome. Neurology. 2015;84(4):359-366.

Clinical question: What characteristics in patients with acute encephalitis portend a worse prognosis?

Background: Acute encephalitis is a serious neurologic disease with high levels of associated morbidity, mortality, and cost of care. Yet, little is known about the factors that affect the outcome of patients with encephalitis.

Study design: Retrospective chart review of all consecutive patients diagnosed with acute encephalitis.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: A retrospective chart review revealed 198 patients with encephalitis, grouped into viral, autoimmune, or unknown/other encephalitis categories, with mortality rates of 8%, 12%, and 5%, respectively. Researchers calculated a modified Rankin Scale score (mRS) on factors associated with good (mRS=0-2) or poor (mRS=3-6) outcome after one year. Factors associated with poor outcome included age 65 or older, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia. Unlike some previous studies, MRI findings and seizure activity did not portend a poor outcome. For viral encephalitis, cerebrospinal fluid polymorphonuclear cell count was also strongly associated with poor outcome.

This is one of the first studies to evaluate functional outcome or distant follow-up; however, it has inherent biases related to the retrospective design, and the results are not necessarily generalizable to all hospitals; there might be an underlying referral bias, given the fact that one third of the patients were referred to the center for further evaluation.

This study does suggest aggressive treatment should be pursued, even in patients with severe presentation, given the possibility of favorable recovery.

Bottom line: Advanced age, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia portend a worse outcome for patients with acute encephalitis.

Citation: Singh TD, Fugate JE, Rabinstein AA. The spectrum of acute encephalitis: causes, management, and predictors of outcome. Neurology. 2015;84(4):359-366.