Yes, we have been here before. Another day, another delay in implementing International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). But, do not expect another postponement. If you are already conducting training sessions to move to the new system come next October, continue to do so. If you have not yet started, now is the time to start. ICD-10-CM is coming to your practice, and it will change everything.

“Why the switch?” you ask?
This change in our diagnostic coding system is required to allow coding for increased specificity in the reporting of diseases and recently recognized conditions as well as to maintain our status with respect to the rest of the world (which has been using ICD-10 for years). It also will be essential to use this coding system with the electronic medical record (EMR), so that meaningful use can be demonstrated more easily. Keep in mind that failure to show meaningful use will lead to penalties in the future. This new system offers improvements over ICD-9-CM in coding primary care encounters, external causes of injury, mental disorders, neoplasms, obstetric complications, and preventive health. It also allows physicians to demonstrate severity of illness in a way that is not possible with ICD-9-CM.

There will be 65,000 more codes than currently exist in ICD-9-CM. No physician will be able to keep all of these code numbers handy, but by making changes to clinician documentation and applying diagnostic coding guidelines correctly within the framework of the new system, the transition will not be onerous. And consider that, while the number of new codes is great, the number of codes used in the typical ObGyn practice will be a fraction of that number.

Related article: As ICD-10 conversion nears, keep these factors in mind to ensure proper reimbursements in 2014. Barbara S. Levy, MD (Audiocast, January 2014)

For ICD-10, documentation is paramount
The most important issue when considering overall coding and practice changes will be recognizing that clinician documentation will be the key to coding the highest level of specificity—and this high level of specificity may be required by most payers when ­deciding to reimburse for treatments rendered. Complete documentation sets the stage for the severity of illness and should in fact result in fewer denials for medical necessity.

For the new process to work efficiently, however, without a lot of delays due to coders and billers having to get more information from clinician offices before sending out claims, your understanding of and “buy-in” to the more clinically specific documentation will be essential.

To explain, under ICD-9-CM coding, simply documenting amenorrhea was acceptable. But when we switch to ICD-10-CM, documentation will need to specify whether the amenorrhea was primary or secondary. This more specific diagnostic coding will make a difference in the health statistics we collect. These data are used for research and to make decisions about allocation of resources—all essential components to excellent quality patient care.

The codes themselves will look different, which may be why some are resisting the change. Instead of the up to five digits required in ICD-9-CM, ICD-10-CM will require up to seven characters. All of the ICD-10-CM codes begin with a letter, may require a placeholder code of “x” as part of the code number, and the seventh character can be either a number or a letter. For instance, with some ICD-10-CM diagnoses reported by ObGyns, a seventh character might require documentation of the encounter as being initial, subsequent, or a sequel; in other cases, that seventh character will be used to identify which fetus has the problem identified by the diagnostic code.

Related article: The economics of surgical gynecology: How we can not only survive, but thrive, in the 21st Century. Q&A with Barbara S. Levy, MD (Practice Management; February 2013)

Your understanding, although not a necessity, is best for all involved
In truth, most clinicians are not familiar with code formats and code numbers within our current ICD-9-CM code set. The expectation that you will suddenly become fluent in ICD-10-CM “code speak” is not realistic. But an understanding of the new codes in relation to documentation expectations will go a long way to making this transition as smooth as possible. For instance, when a patient currently presents reporting vaginal pain that is found to be due to erosion of a previously placed mesh, the code 628.31 (Erosion of implanted vaginal mesh and other prosthetic materials to surrounding organ or tissue) is  reported. But in ICD-10-CM, the documentation would need to include whether this was an initial encounter and the code would become T83.711A (Erosion of implanted vaginal mesh and other prosthetic materials to surrounding organ or tissue, initial encounter).

Smart search. The good news is that most EMR products will have a “smart search” program available for clinicians to pick the correct code based on the search criteria. The bad news is that you will have to be a bit more exact in the search terms you use to make the process easy. For instance, the patient has pelvic pain but you search only on the term “pain.” That term by itself will result in about 100 codes to select from, and the order of the codes may mean that the correct code for pelvic pain is 25 codes down the list. However, if you instead search on the term “pelvic pain,” the one and only code for this condition will be listed and you can simply select it and move on.

Develop cheat sheets. Health-care professionals who are not using an EMR or some sort of computerized code search program will have a harder time, but the use of multiple paper “cheat sheets” for general gynecology, family planning, surgical cases, urology, infertility, obstetrics, etc., will ease that burden. Practice management staff can develop these forms, built on the codes that are currently being reported by the clinician. Place all of the options to replace the older code on the sheet so the correct selection can be made.

For instance, if the provider previously had reported vaginitis with one code, when we move to ICD-10-CM the code would expand to four code selections based on documentation of acute vaginitis, subacute and chronic vaginitis, acute vulvitis, or subacute and chronic vulvitis. If you only had documented vaginitis in the medical record, this gives you the opportunity to refine the documentation to something more specific that supports selection of the correct code and supports the medical need for management options.

Related article: Dos, don’ts, and dollars: Making the switch to an HER. Neil H. Baum, MD; Paul Kepper, MS. (Practice Management; November 2013)

Take advantage of the extra time
Now that we have a delay in the rollout, take this time to critically examine your documentation styles, and practice selecting ICD-10-CM codes before it counts toward payment or nonpayment of a claim. When the time comes, your practice will be fluent in the new system and there will be no delays in getting claims out the door or payment due to incorrect diagnostic coding. In other words, practice makes perfect.

In fact, some ObGyn practices that were ready for the new system have decided to switch to ICD-10-CM coding as of October 1, 2014. They will code each encounter by reporting both the ICD-9-CM code and the ICD-10-CM code on the revised CMS claim form or electronic billing format that permits dual diagnostic coding. This type of experience will ensure that all physicians and other health-care professionals in the practice have ample opportunity to improve their documentation and make any adjustments before the 2015 deadline.

Related article: The 2014 CPT and Medicare code changes affecting ObGyn practice. Melanie Witt, RN, CPC, COBGC, MA (Reimbursement Adviser; January 2014)

WE WANT TO HEAR FROM YOU!
Drop us a line and let us know what you think about current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected]

Yes, we have been here before. Another day, another delay in implementing International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). But, do not expect another postponement. If you are already conducting training sessions to move to the new system come next October, continue to do so. If you have not yet started, now is the time to start. ICD-10-CM is coming to your practice, and it will change everything.

“Why the switch?” you ask?
This change in our diagnostic coding system is required to allow coding for increased specificity in the reporting of diseases and recently recognized conditions as well as to maintain our status with respect to the rest of the world (which has been using ICD-10 for years). It also will be essential to use this coding system with the electronic medical record (EMR), so that meaningful use can be demonstrated more easily. Keep in mind that failure to show meaningful use will lead to penalties in the future. This new system offers improvements over ICD-9-CM in coding primary care encounters, external causes of injury, mental disorders, neoplasms, obstetric complications, and preventive health. It also allows physicians to demonstrate severity of illness in a way that is not possible with ICD-9-CM.

There will be 65,000 more codes than currently exist in ICD-9-CM. No physician will be able to keep all of these code numbers handy, but by making changes to clinician documentation and applying diagnostic coding guidelines correctly within the framework of the new system, the transition will not be onerous. And consider that, while the number of new codes is great, the number of codes used in the typical ObGyn practice will be a fraction of that number.

Related article: As ICD-10 conversion nears, keep these factors in mind to ensure proper reimbursements in 2014. Barbara S. Levy, MD (Audiocast, January 2014)

For ICD-10, documentation is paramount
The most important issue when considering overall coding and practice changes will be recognizing that clinician documentation will be the key to coding the highest level of specificity—and this high level of specificity may be required by most payers when ­deciding to reimburse for treatments rendered. Complete documentation sets the stage for the severity of illness and should in fact result in fewer denials for medical necessity.

For the new process to work efficiently, however, without a lot of delays due to coders and billers having to get more information from clinician offices before sending out claims, your understanding of and “buy-in” to the more clinically specific documentation will be essential.

To explain, under ICD-9-CM coding, simply documenting amenorrhea was acceptable. But when we switch to ICD-10-CM, documentation will need to specify whether the amenorrhea was primary or secondary. This more specific diagnostic coding will make a difference in the health statistics we collect. These data are used for research and to make decisions about allocation of resources—all essential components to excellent quality patient care.

The codes themselves will look different, which may be why some are resisting the change. Instead of the up to five digits required in ICD-9-CM, ICD-10-CM will require up to seven characters. All of the ICD-10-CM codes begin with a letter, may require a placeholder code of “x” as part of the code number, and the seventh character can be either a number or a letter. For instance, with some ICD-10-CM diagnoses reported by ObGyns, a seventh character might require documentation of the encounter as being initial, subsequent, or a sequel; in other cases, that seventh character will be used to identify which fetus has the problem identified by the diagnostic code.

Related article: The economics of surgical gynecology: How we can not only survive, but thrive, in the 21st Century. Q&A with Barbara S. Levy, MD (Practice Management; February 2013)

Your understanding, although not a necessity, is best for all involved
In truth, most clinicians are not familiar with code formats and code numbers within our current ICD-9-CM code set. The expectation that you will suddenly become fluent in ICD-10-CM “code speak” is not realistic. But an understanding of the new codes in relation to documentation expectations will go a long way to making this transition as smooth as possible. For instance, when a patient currently presents reporting vaginal pain that is found to be due to erosion of a previously placed mesh, the code 628.31 (Erosion of implanted vaginal mesh and other prosthetic materials to surrounding organ or tissue) is  reported. But in ICD-10-CM, the documentation would need to include whether this was an initial encounter and the code would become T83.711A (Erosion of implanted vaginal mesh and other prosthetic materials to surrounding organ or tissue, initial encounter).

Smart search. The good news is that most EMR products will have a “smart search” program available for clinicians to pick the correct code based on the search criteria. The bad news is that you will have to be a bit more exact in the search terms you use to make the process easy. For instance, the patient has pelvic pain but you search only on the term “pain.” That term by itself will result in about 100 codes to select from, and the order of the codes may mean that the correct code for pelvic pain is 25 codes down the list. However, if you instead search on the term “pelvic pain,” the one and only code for this condition will be listed and you can simply select it and move on.

Develop cheat sheets. Health-care professionals who are not using an EMR or some sort of computerized code search program will have a harder time, but the use of multiple paper “cheat sheets” for general gynecology, family planning, surgical cases, urology, infertility, obstetrics, etc., will ease that burden. Practice management staff can develop these forms, built on the codes that are currently being reported by the clinician. Place all of the options to replace the older code on the sheet so the correct selection can be made.

For instance, if the provider previously had reported vaginitis with one code, when we move to ICD-10-CM the code would expand to four code selections based on documentation of acute vaginitis, subacute and chronic vaginitis, acute vulvitis, or subacute and chronic vulvitis. If you only had documented vaginitis in the medical record, this gives you the opportunity to refine the documentation to something more specific that supports selection of the correct code and supports the medical need for management options.

Related article: Dos, don’ts, and dollars: Making the switch to an HER. Neil H. Baum, MD; Paul Kepper, MS. (Practice Management; November 2013)

Take advantage of the extra time
Now that we have a delay in the rollout, take this time to critically examine your documentation styles, and practice selecting ICD-10-CM codes before it counts toward payment or nonpayment of a claim. When the time comes, your practice will be fluent in the new system and there will be no delays in getting claims out the door or payment due to incorrect diagnostic coding. In other words, practice makes perfect.

In fact, some ObGyn practices that were ready for the new system have decided to switch to ICD-10-CM coding as of October 1, 2014. They will code each encounter by reporting both the ICD-9-CM code and the ICD-10-CM code on the revised CMS claim form or electronic billing format that permits dual diagnostic coding. This type of experience will ensure that all physicians and other health-care professionals in the practice have ample opportunity to improve their documentation and make any adjustments before the 2015 deadline.

Related article: The 2014 CPT and Medicare code changes affecting ObGyn practice. Melanie Witt, RN, CPC, COBGC, MA (Reimbursement Adviser; January 2014)

WE WANT TO HEAR FROM YOU!
Drop us a line and let us know what you think about current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected]

Yes, we have been here before. Another day, another delay in implementing International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). But, do not expect another postponement. If you are already conducting training sessions to move to the new system come next October, continue to do so. If you have not yet started, now is the time to start. ICD-10-CM is coming to your practice, and it will change everything.

“Why the switch?” you ask?
This change in our diagnostic coding system is required to allow coding for increased specificity in the reporting of diseases and recently recognized conditions as well as to maintain our status with respect to the rest of the world (which has been using ICD-10 for years). It also will be essential to use this coding system with the electronic medical record (EMR), so that meaningful use can be demonstrated more easily. Keep in mind that failure to show meaningful use will lead to penalties in the future. This new system offers improvements over ICD-9-CM in coding primary care encounters, external causes of injury, mental disorders, neoplasms, obstetric complications, and preventive health. It also allows physicians to demonstrate severity of illness in a way that is not possible with ICD-9-CM.

There will be 65,000 more codes than currently exist in ICD-9-CM. No physician will be able to keep all of these code numbers handy, but by making changes to clinician documentation and applying diagnostic coding guidelines correctly within the framework of the new system, the transition will not be onerous. And consider that, while the number of new codes is great, the number of codes used in the typical ObGyn practice will be a fraction of that number.

Related article: As ICD-10 conversion nears, keep these factors in mind to ensure proper reimbursements in 2014. Barbara S. Levy, MD (Audiocast, January 2014)

For ICD-10, documentation is paramount
The most important issue when considering overall coding and practice changes will be recognizing that clinician documentation will be the key to coding the highest level of specificity—and this high level of specificity may be required by most payers when ­deciding to reimburse for treatments rendered. Complete documentation sets the stage for the severity of illness and should in fact result in fewer denials for medical necessity.

For the new process to work efficiently, however, without a lot of delays due to coders and billers having to get more information from clinician offices before sending out claims, your understanding of and “buy-in” to the more clinically specific documentation will be essential.

To explain, under ICD-9-CM coding, simply documenting amenorrhea was acceptable. But when we switch to ICD-10-CM, documentation will need to specify whether the amenorrhea was primary or secondary. This more specific diagnostic coding will make a difference in the health statistics we collect. These data are used for research and to make decisions about allocation of resources—all essential components to excellent quality patient care.

The codes themselves will look different, which may be why some are resisting the change. Instead of the up to five digits required in ICD-9-CM, ICD-10-CM will require up to seven characters. All of the ICD-10-CM codes begin with a letter, may require a placeholder code of “x” as part of the code number, and the seventh character can be either a number or a letter. For instance, with some ICD-10-CM diagnoses reported by ObGyns, a seventh character might require documentation of the encounter as being initial, subsequent, or a sequel; in other cases, that seventh character will be used to identify which fetus has the problem identified by the diagnostic code.

Related article: The economics of surgical gynecology: How we can not only survive, but thrive, in the 21st Century. Q&A with Barbara S. Levy, MD (Practice Management; February 2013)

Your understanding, although not a necessity, is best for all involved
In truth, most clinicians are not familiar with code formats and code numbers within our current ICD-9-CM code set. The expectation that you will suddenly become fluent in ICD-10-CM “code speak” is not realistic. But an understanding of the new codes in relation to documentation expectations will go a long way to making this transition as smooth as possible. For instance, when a patient currently presents reporting vaginal pain that is found to be due to erosion of a previously placed mesh, the code 628.31 (Erosion of implanted vaginal mesh and other prosthetic materials to surrounding organ or tissue) is  reported. But in ICD-10-CM, the documentation would need to include whether this was an initial encounter and the code would become T83.711A (Erosion of implanted vaginal mesh and other prosthetic materials to surrounding organ or tissue, initial encounter).

Smart search. The good news is that most EMR products will have a “smart search” program available for clinicians to pick the correct code based on the search criteria. The bad news is that you will have to be a bit more exact in the search terms you use to make the process easy. For instance, the patient has pelvic pain but you search only on the term “pain.” That term by itself will result in about 100 codes to select from, and the order of the codes may mean that the correct code for pelvic pain is 25 codes down the list. However, if you instead search on the term “pelvic pain,” the one and only code for this condition will be listed and you can simply select it and move on.

Develop cheat sheets. Health-care professionals who are not using an EMR or some sort of computerized code search program will have a harder time, but the use of multiple paper “cheat sheets” for general gynecology, family planning, surgical cases, urology, infertility, obstetrics, etc., will ease that burden. Practice management staff can develop these forms, built on the codes that are currently being reported by the clinician. Place all of the options to replace the older code on the sheet so the correct selection can be made.

For instance, if the provider previously had reported vaginitis with one code, when we move to ICD-10-CM the code would expand to four code selections based on documentation of acute vaginitis, subacute and chronic vaginitis, acute vulvitis, or subacute and chronic vulvitis. If you only had documented vaginitis in the medical record, this gives you the opportunity to refine the documentation to something more specific that supports selection of the correct code and supports the medical need for management options.

Related article: Dos, don’ts, and dollars: Making the switch to an HER. Neil H. Baum, MD; Paul Kepper, MS. (Practice Management; November 2013)

Take advantage of the extra time
Now that we have a delay in the rollout, take this time to critically examine your documentation styles, and practice selecting ICD-10-CM codes before it counts toward payment or nonpayment of a claim. When the time comes, your practice will be fluent in the new system and there will be no delays in getting claims out the door or payment due to incorrect diagnostic coding. In other words, practice makes perfect.

In fact, some ObGyn practices that were ready for the new system have decided to switch to ICD-10-CM coding as of October 1, 2014. They will code each encounter by reporting both the ICD-9-CM code and the ICD-10-CM code on the revised CMS claim form or electronic billing format that permits dual diagnostic coding. This type of experience will ensure that all physicians and other health-care professionals in the practice have ample opportunity to improve their documentation and make any adjustments before the 2015 deadline.

Related article: The 2014 CPT and Medicare code changes affecting ObGyn practice. Melanie Witt, RN, CPC, COBGC, MA (Reimbursement Adviser; January 2014)

WE WANT TO HEAR FROM YOU!
Drop us a line and let us know what you think about current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected]

The alleged STAP cells

Credit: Haruko Obokata

The journal Nature has retracted the papers it published several months ago on stimulus-triggered acquisition of pluripotency (STAP) cells.

In January, Nature published an article and a letter in which researchers claimed they could create STAP cells—ie, induce pluripotency in somatic cells by exposing them to a low-pH environment.

Not long after the papers were published, however, members of the scientific community began to question the validity of the research.

They voiced concerns about published images, possible plagiarism, and an inability to replicate the experiments described.

So the Japanese institute RIKEN, where most of the study’s investigators are employed, launched an investigation.

In April, RIKEN’s investigative committee concluded that lead study author Haruko Obokata, PhD, and some of her colleagues were guilty of misconduct and/or negligence.

Dr Obokata appealed the findings, saying the acts of misconduct were simply mistakes and that STAP cells do exist.

But the committee decided another investigation is not warranted, and RIKEN called for a retraction of the Nature papers.

Today, Nature published the retractions, which can be viewed here and here. An editorial on the subject is available here.

As for the future of STAP cells, RIKEN is currently attempting to recreate Dr Obokata’s experiments and determine if the cells do exist. The organization plans to release an interim report on this attempt in late July or early August.

Other researchers said they have tried and failed to replicate Dr Obokata’s experiments. One group detailed their failed attempt in F1000Research.

The alleged STAP cells

Credit: Haruko Obokata

The journal Nature has retracted the papers it published several months ago on stimulus-triggered acquisition of pluripotency (STAP) cells.

In January, Nature published an article and a letter in which researchers claimed they could create STAP cells—ie, induce pluripotency in somatic cells by exposing them to a low-pH environment.

Not long after the papers were published, however, members of the scientific community began to question the validity of the research.

They voiced concerns about published images, possible plagiarism, and an inability to replicate the experiments described.

So the Japanese institute RIKEN, where most of the study’s investigators are employed, launched an investigation.

In April, RIKEN’s investigative committee concluded that lead study author Haruko Obokata, PhD, and some of her colleagues were guilty of misconduct and/or negligence.

Dr Obokata appealed the findings, saying the acts of misconduct were simply mistakes and that STAP cells do exist.

But the committee decided another investigation is not warranted, and RIKEN called for a retraction of the Nature papers.

Today, Nature published the retractions, which can be viewed here and here. An editorial on the subject is available here.

As for the future of STAP cells, RIKEN is currently attempting to recreate Dr Obokata’s experiments and determine if the cells do exist. The organization plans to release an interim report on this attempt in late July or early August.

Other researchers said they have tried and failed to replicate Dr Obokata’s experiments. One group detailed their failed attempt in F1000Research.

The alleged STAP cells

Credit: Haruko Obokata

The journal Nature has retracted the papers it published several months ago on stimulus-triggered acquisition of pluripotency (STAP) cells.

In January, Nature published an article and a letter in which researchers claimed they could create STAP cells—ie, induce pluripotency in somatic cells by exposing them to a low-pH environment.

Not long after the papers were published, however, members of the scientific community began to question the validity of the research.

They voiced concerns about published images, possible plagiarism, and an inability to replicate the experiments described.

So the Japanese institute RIKEN, where most of the study’s investigators are employed, launched an investigation.

In April, RIKEN’s investigative committee concluded that lead study author Haruko Obokata, PhD, and some of her colleagues were guilty of misconduct and/or negligence.

Dr Obokata appealed the findings, saying the acts of misconduct were simply mistakes and that STAP cells do exist.

But the committee decided another investigation is not warranted, and RIKEN called for a retraction of the Nature papers.

Today, Nature published the retractions, which can be viewed here and here. An editorial on the subject is available here.

As for the future of STAP cells, RIKEN is currently attempting to recreate Dr Obokata’s experiments and determine if the cells do exist. The organization plans to release an interim report on this attempt in late July or early August.

Other researchers said they have tried and failed to replicate Dr Obokata’s experiments. One group detailed their failed attempt in F1000Research.

Syringe

Bristol-Myers Squibb has announced a recall of 6 lots of the anticoagulant warfarin, sold as Coumadin for Injection in 5 mg single-use vials, in the US.

The company is recalling these lots after discovering visible particulate matter in unreleased samples of the drug.

The company said the safety risk to patients is likely low and is further mitigated by the product’s prescribing information, which advises that intravenous products be inspected visually before administration.

However, injected particulate metallic and non-metallic cellulose material can cause serious and potentially fatal adverse reactions, such as embolization. Allergic reactions to the foreign material could also occur.

To date, there have been no product complaints or adverse events reported to Bristol-Myers Squibb related to particulate matter in Coumadin for Injection.

Coumadin for Injection was discontinued in early April 2014. The oral formulation of Coumadin is not impacted by this recall.

Coumadin for Injection is packaged in cartons of six 5-mg single-use vials. The affected product includes the following 6 lots distributed to hospitals and pharmacies from November 2011 through January 2014:

Lot #       Description                                NDC                    Expiration

201125    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    Sept. 2014

201126    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    Nov. 2014

201127    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    Dec. 2014

201228    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    June 2015

201229    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    July 2015

201230    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    Sept. 2015

Anyone with the aforementioned lots of Coumadin for Injection should stop using or distributing the product and contact Bristol-Myers Squibb’s recall vendor, GENCO, at 1-855-838-5784 to arrange for the return of remaining stock.

Customers with questions about the recall may contact the Bristol-Myers Squibb Customer Information Center at 1-800-332-2056.

Adverse reactions or quality problems associated with the use of this product can be reported to the FDA’s MedWatch Adverse Event Reporting Program.

Syringe

Bristol-Myers Squibb has announced a recall of 6 lots of the anticoagulant warfarin, sold as Coumadin for Injection in 5 mg single-use vials, in the US.

The company is recalling these lots after discovering visible particulate matter in unreleased samples of the drug.

The company said the safety risk to patients is likely low and is further mitigated by the product’s prescribing information, which advises that intravenous products be inspected visually before administration.

However, injected particulate metallic and non-metallic cellulose material can cause serious and potentially fatal adverse reactions, such as embolization. Allergic reactions to the foreign material could also occur.

To date, there have been no product complaints or adverse events reported to Bristol-Myers Squibb related to particulate matter in Coumadin for Injection.

Coumadin for Injection was discontinued in early April 2014. The oral formulation of Coumadin is not impacted by this recall.

Coumadin for Injection is packaged in cartons of six 5-mg single-use vials. The affected product includes the following 6 lots distributed to hospitals and pharmacies from November 2011 through January 2014:

Lot #       Description                                NDC                    Expiration

201125    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    Sept. 2014

201126    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    Nov. 2014

201127    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    Dec. 2014

201228    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    June 2015

201229    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    July 2015

201230    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    Sept. 2015

Anyone with the aforementioned lots of Coumadin for Injection should stop using or distributing the product and contact Bristol-Myers Squibb’s recall vendor, GENCO, at 1-855-838-5784 to arrange for the return of remaining stock.

Customers with questions about the recall may contact the Bristol-Myers Squibb Customer Information Center at 1-800-332-2056.

Adverse reactions or quality problems associated with the use of this product can be reported to the FDA’s MedWatch Adverse Event Reporting Program.

Syringe

Bristol-Myers Squibb has announced a recall of 6 lots of the anticoagulant warfarin, sold as Coumadin for Injection in 5 mg single-use vials, in the US.

The company is recalling these lots after discovering visible particulate matter in unreleased samples of the drug.

The company said the safety risk to patients is likely low and is further mitigated by the product’s prescribing information, which advises that intravenous products be inspected visually before administration.

However, injected particulate metallic and non-metallic cellulose material can cause serious and potentially fatal adverse reactions, such as embolization. Allergic reactions to the foreign material could also occur.

To date, there have been no product complaints or adverse events reported to Bristol-Myers Squibb related to particulate matter in Coumadin for Injection.

Coumadin for Injection was discontinued in early April 2014. The oral formulation of Coumadin is not impacted by this recall.

Coumadin for Injection is packaged in cartons of six 5-mg single-use vials. The affected product includes the following 6 lots distributed to hospitals and pharmacies from November 2011 through January 2014:

Lot #       Description                                NDC                    Expiration

201125    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    Sept. 2014

201126    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    Nov. 2014

201127    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    Dec. 2014

201228    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    June 2015

201229    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    July 2015

201230    COUMADIN LINJ 5MG (6VL) US    0590-0324-35    Sept. 2015

Anyone with the aforementioned lots of Coumadin for Injection should stop using or distributing the product and contact Bristol-Myers Squibb’s recall vendor, GENCO, at 1-855-838-5784 to arrange for the return of remaining stock.

Customers with questions about the recall may contact the Bristol-Myers Squibb Customer Information Center at 1-800-332-2056.

Adverse reactions or quality problems associated with the use of this product can be reported to the FDA’s MedWatch Adverse Event Reporting Program.

The US Food and Drug Administration (FDA) has granted the bispecific antibody blinatumomab breakthrough designation for the treatment of adults with relapsed or refractory B-precursor acute lymphoblastic leukemia (B-ALL).

The decision was based on promising results of a phase 2 trial, which were presented at the 50th Annual Meeting of the American Society of Clinical Oncology (ASCO) and the 19th Congress of the European Hematology Association (EHA).

According to the FDA, breakthrough designation is intended to expedite the development and review of drugs for serious or life-threatening conditions.

For a treatment to receive this designation, there must be preliminary clinical evidence suggesting the drug may offer substantial improvement over currently available therapy on at least one clinically significant endpoint.

Trial results

Nicola Gökbuget, MD, of Goethe University in Frankfurt, Germany, and Max Topp, MD, of the University of Wuerzberg in Germany, presented phase 2 results with blinatumomab at the EHA Congress as abstracts S1314 and S722. The trial was sponsored by Amgen, the company developing blinatumomab.

“Blinatumomab is a bispecific antibody which has two parts,” Dr Gökbuget noted. “With one part—the CD3 part—it attracts T cells, and with the other part, it binds to CD19. And CD19 is a target available on the vast majority of B-precursor ALL blast cells.”

To test this mechanism, Dr Gökbuget and her colleagues evaluated blinatumomab monotherapy in 189 patients with relapsed or refractory B-ALL and a median age of 39 (range, 18-79).

The patients received blinatumomab by continuous intravenous infusion—4 weeks on and 2 weeks off—for up to 5 cycles.

Safety

Dr Gökbuget noted that major toxicities were related to cytokine release syndrome—for example, fever and headache—but cytopenias were also common.

“Another side effect observed with this compound—and this is something seen often with other T-cell therapies—was [central nervous system] events,” she added.

The most frequent adverse events (AEs) were pyrexia (59%), headache (35%) and febrile neutropenia (29%). The most frequent grade 3 or higher AEs were febrile neutropenia (26%), anemia (15%), and neutropenia (15%). Two percent of patients had grade 3 or higher cytokine release syndrome.

The most common grade 3 or higher nervous system AEs were headache (4%), encephalopathy (3%), and ataxia (2%). Three patients (2%) had grade 5 AEs considered treatment-related—2 with sepsis and 1 with Candida infection.

Efficacy

The study’s primary endpoint was complete remission (CR) or CR with partial hematologic recovery (CRh) within the first 2 cycles.

An exploratory endpoint was minimal residual disease (MRD) response (<10^-4) within the first 2 cycles. If a patient was MRD-negative, he was classified as having a complete MRD response.

In all, 43% (81/189) of patients achieved a CR/CRh within 2 cycles of therapy. Thirty-three percent (63/189) achieved a CR, and 9% (18/189) achieved a CRh.

Eighty-two percent (60/73) of patients with a CR/CRh who were evaluable for an MRD assessment achieved an MRD response. This included 86% (50/58) of CR patients and 67% (10/15) of CRh patients. Seventy-one percent (51/73) of patients with CR/CRh had a complete MRD response.

The median relapse-free survival was 5.9 months.

“So to conclude, we have observed considerable antileukemic activity for this single-drug therapy,” Dr Gökbuget said. “We have to keep in mind this is a single drug, and, usually, these patients receive many different chemotherapy compounds.”

“Also, although these patients were poorly selected, this is, so far, the largest trial in adult ALL where standardized PCR-based MRD detection was tested in the relapsed setting. So these data will be very important.”

The US Food and Drug Administration (FDA) has granted the bispecific antibody blinatumomab breakthrough designation for the treatment of adults with relapsed or refractory B-precursor acute lymphoblastic leukemia (B-ALL).

The decision was based on promising results of a phase 2 trial, which were presented at the 50th Annual Meeting of the American Society of Clinical Oncology (ASCO) and the 19th Congress of the European Hematology Association (EHA).

According to the FDA, breakthrough designation is intended to expedite the development and review of drugs for serious or life-threatening conditions.

For a treatment to receive this designation, there must be preliminary clinical evidence suggesting the drug may offer substantial improvement over currently available therapy on at least one clinically significant endpoint.

Trial results

Nicola Gökbuget, MD, of Goethe University in Frankfurt, Germany, and Max Topp, MD, of the University of Wuerzberg in Germany, presented phase 2 results with blinatumomab at the EHA Congress as abstracts S1314 and S722. The trial was sponsored by Amgen, the company developing blinatumomab.

“Blinatumomab is a bispecific antibody which has two parts,” Dr Gökbuget noted. “With one part—the CD3 part—it attracts T cells, and with the other part, it binds to CD19. And CD19 is a target available on the vast majority of B-precursor ALL blast cells.”

To test this mechanism, Dr Gökbuget and her colleagues evaluated blinatumomab monotherapy in 189 patients with relapsed or refractory B-ALL and a median age of 39 (range, 18-79).

The patients received blinatumomab by continuous intravenous infusion—4 weeks on and 2 weeks off—for up to 5 cycles.

Safety

Dr Gökbuget noted that major toxicities were related to cytokine release syndrome—for example, fever and headache—but cytopenias were also common.

“Another side effect observed with this compound—and this is something seen often with other T-cell therapies—was [central nervous system] events,” she added.

The most frequent adverse events (AEs) were pyrexia (59%), headache (35%) and febrile neutropenia (29%). The most frequent grade 3 or higher AEs were febrile neutropenia (26%), anemia (15%), and neutropenia (15%). Two percent of patients had grade 3 or higher cytokine release syndrome.

The most common grade 3 or higher nervous system AEs were headache (4%), encephalopathy (3%), and ataxia (2%). Three patients (2%) had grade 5 AEs considered treatment-related—2 with sepsis and 1 with Candida infection.

Efficacy

The study’s primary endpoint was complete remission (CR) or CR with partial hematologic recovery (CRh) within the first 2 cycles.

An exploratory endpoint was minimal residual disease (MRD) response (<10^-4) within the first 2 cycles. If a patient was MRD-negative, he was classified as having a complete MRD response.

In all, 43% (81/189) of patients achieved a CR/CRh within 2 cycles of therapy. Thirty-three percent (63/189) achieved a CR, and 9% (18/189) achieved a CRh.

Eighty-two percent (60/73) of patients with a CR/CRh who were evaluable for an MRD assessment achieved an MRD response. This included 86% (50/58) of CR patients and 67% (10/15) of CRh patients. Seventy-one percent (51/73) of patients with CR/CRh had a complete MRD response.

The median relapse-free survival was 5.9 months.

“So to conclude, we have observed considerable antileukemic activity for this single-drug therapy,” Dr Gökbuget said. “We have to keep in mind this is a single drug, and, usually, these patients receive many different chemotherapy compounds.”

“Also, although these patients were poorly selected, this is, so far, the largest trial in adult ALL where standardized PCR-based MRD detection was tested in the relapsed setting. So these data will be very important.”

The US Food and Drug Administration (FDA) has granted the bispecific antibody blinatumomab breakthrough designation for the treatment of adults with relapsed or refractory B-precursor acute lymphoblastic leukemia (B-ALL).

The decision was based on promising results of a phase 2 trial, which were presented at the 50th Annual Meeting of the American Society of Clinical Oncology (ASCO) and the 19th Congress of the European Hematology Association (EHA).

According to the FDA, breakthrough designation is intended to expedite the development and review of drugs for serious or life-threatening conditions.

For a treatment to receive this designation, there must be preliminary clinical evidence suggesting the drug may offer substantial improvement over currently available therapy on at least one clinically significant endpoint.

Trial results

Nicola Gökbuget, MD, of Goethe University in Frankfurt, Germany, and Max Topp, MD, of the University of Wuerzberg in Germany, presented phase 2 results with blinatumomab at the EHA Congress as abstracts S1314 and S722. The trial was sponsored by Amgen, the company developing blinatumomab.

“Blinatumomab is a bispecific antibody which has two parts,” Dr Gökbuget noted. “With one part—the CD3 part—it attracts T cells, and with the other part, it binds to CD19. And CD19 is a target available on the vast majority of B-precursor ALL blast cells.”

To test this mechanism, Dr Gökbuget and her colleagues evaluated blinatumomab monotherapy in 189 patients with relapsed or refractory B-ALL and a median age of 39 (range, 18-79).

The patients received blinatumomab by continuous intravenous infusion—4 weeks on and 2 weeks off—for up to 5 cycles.

Safety

Dr Gökbuget noted that major toxicities were related to cytokine release syndrome—for example, fever and headache—but cytopenias were also common.

“Another side effect observed with this compound—and this is something seen often with other T-cell therapies—was [central nervous system] events,” she added.

The most frequent adverse events (AEs) were pyrexia (59%), headache (35%) and febrile neutropenia (29%). The most frequent grade 3 or higher AEs were febrile neutropenia (26%), anemia (15%), and neutropenia (15%). Two percent of patients had grade 3 or higher cytokine release syndrome.

The most common grade 3 or higher nervous system AEs were headache (4%), encephalopathy (3%), and ataxia (2%). Three patients (2%) had grade 5 AEs considered treatment-related—2 with sepsis and 1 with Candida infection.

Efficacy

The study’s primary endpoint was complete remission (CR) or CR with partial hematologic recovery (CRh) within the first 2 cycles.

An exploratory endpoint was minimal residual disease (MRD) response (<10^-4) within the first 2 cycles. If a patient was MRD-negative, he was classified as having a complete MRD response.

In all, 43% (81/189) of patients achieved a CR/CRh within 2 cycles of therapy. Thirty-three percent (63/189) achieved a CR, and 9% (18/189) achieved a CRh.

Eighty-two percent (60/73) of patients with a CR/CRh who were evaluable for an MRD assessment achieved an MRD response. This included 86% (50/58) of CR patients and 67% (10/15) of CRh patients. Seventy-one percent (51/73) of patients with CR/CRh had a complete MRD response.

The median relapse-free survival was 5.9 months.

“So to conclude, we have observed considerable antileukemic activity for this single-drug therapy,” Dr Gökbuget said. “We have to keep in mind this is a single drug, and, usually, these patients receive many different chemotherapy compounds.”

“Also, although these patients were poorly selected, this is, so far, the largest trial in adult ALL where standardized PCR-based MRD detection was tested in the relapsed setting. So these data will be very important.”

Highlights from The Hospitalist this month include hospitalist reactions to the once-again delayed implementation of the coding classification system ICD-10. Robert Tennant, senior policy advisor at Medical Group Management Association, shares his organization’s perspective on the postponement. Dr. Amy Boutwell, a hospitalist at Newton-Wellesley Hospital and president of Collaborative Healthcare Strategies, discusses Medicare’s new hospital discharge rules and the opportunity they hold for hospitalists. Elsewhere in this issue, we have an update on SHM’s Leadership Academy scheduled for November 3–6 in Honolulu, Hawaii, and the latest in clinical research, including a review of best practices for end-of-life care and when to suspect Kawasaki disease in infants.

Click here to listen to the July highlights Podcast.

Highlights from The Hospitalist this month include hospitalist reactions to the once-again delayed implementation of the coding classification system ICD-10. Robert Tennant, senior policy advisor at Medical Group Management Association, shares his organization’s perspective on the postponement. Dr. Amy Boutwell, a hospitalist at Newton-Wellesley Hospital and president of Collaborative Healthcare Strategies, discusses Medicare’s new hospital discharge rules and the opportunity they hold for hospitalists. Elsewhere in this issue, we have an update on SHM’s Leadership Academy scheduled for November 3–6 in Honolulu, Hawaii, and the latest in clinical research, including a review of best practices for end-of-life care and when to suspect Kawasaki disease in infants.

Click here to listen to the July highlights Podcast.

Highlights from The Hospitalist this month include hospitalist reactions to the once-again delayed implementation of the coding classification system ICD-10. Robert Tennant, senior policy advisor at Medical Group Management Association, shares his organization’s perspective on the postponement. Dr. Amy Boutwell, a hospitalist at Newton-Wellesley Hospital and president of Collaborative Healthcare Strategies, discusses Medicare’s new hospital discharge rules and the opportunity they hold for hospitalists. Elsewhere in this issue, we have an update on SHM’s Leadership Academy scheduled for November 3–6 in Honolulu, Hawaii, and the latest in clinical research, including a review of best practices for end-of-life care and when to suspect Kawasaki disease in infants.

Click here to listen to the July highlights Podcast.

Dr. George

Dr. George is president of the central business unit for Brentwood, Tenn.-based Cogent Healthcare, the largest privately held hospital medicine company in the United States. She oversees multiple HM programs in the north central region of the U.S. Previously, she was medical director of hospitalist services for OSF St. Anthony Medical Center in Rockford, Ill.

Undergraduate education: Dr. George went straight from high school to a direct medical program and earned her MBA at the University of Tennessee in Knoxville.

Medical school: JJM Medical College in India.

Notable: She began her MBA at the University of Tennessee when she was 34 weeks pregnant, proving wrong the professors who thought she would not be able to finish the program. Actively involved in the SHM Leadership, RIV, and Annual Meeting committees, Dr. George is a frequent annual meeting presenter on women’s workforce issues.

FYI: Dr. George keeps busy with her two children, ages 15 and 9, supporting them in such extra-curricular pursuits as marching band, music lessons, tae kwon do, and chess. In her downtime, she likes to relax by watching movies and spending time with friends.

Quotable: “It is a tremendous honor to be a Fellow in Hospital Medicine; it demonstrates clearly to everyone my accomplishments as a hospitalist, and I am proud to have been a member of the inaugural class of fellows.”

Dr. George

Dr. George is president of the central business unit for Brentwood, Tenn.-based Cogent Healthcare, the largest privately held hospital medicine company in the United States. She oversees multiple HM programs in the north central region of the U.S. Previously, she was medical director of hospitalist services for OSF St. Anthony Medical Center in Rockford, Ill.

Undergraduate education: Dr. George went straight from high school to a direct medical program and earned her MBA at the University of Tennessee in Knoxville.

Medical school: JJM Medical College in India.

Notable: She began her MBA at the University of Tennessee when she was 34 weeks pregnant, proving wrong the professors who thought she would not be able to finish the program. Actively involved in the SHM Leadership, RIV, and Annual Meeting committees, Dr. George is a frequent annual meeting presenter on women’s workforce issues.

FYI: Dr. George keeps busy with her two children, ages 15 and 9, supporting them in such extra-curricular pursuits as marching band, music lessons, tae kwon do, and chess. In her downtime, she likes to relax by watching movies and spending time with friends.

Quotable: “It is a tremendous honor to be a Fellow in Hospital Medicine; it demonstrates clearly to everyone my accomplishments as a hospitalist, and I am proud to have been a member of the inaugural class of fellows.”

Dr. George

Dr. George is president of the central business unit for Brentwood, Tenn.-based Cogent Healthcare, the largest privately held hospital medicine company in the United States. She oversees multiple HM programs in the north central region of the U.S. Previously, she was medical director of hospitalist services for OSF St. Anthony Medical Center in Rockford, Ill.

Undergraduate education: Dr. George went straight from high school to a direct medical program and earned her MBA at the University of Tennessee in Knoxville.

Medical school: JJM Medical College in India.

Notable: She began her MBA at the University of Tennessee when she was 34 weeks pregnant, proving wrong the professors who thought she would not be able to finish the program. Actively involved in the SHM Leadership, RIV, and Annual Meeting committees, Dr. George is a frequent annual meeting presenter on women’s workforce issues.

FYI: Dr. George keeps busy with her two children, ages 15 and 9, supporting them in such extra-curricular pursuits as marching band, music lessons, tae kwon do, and chess. In her downtime, she likes to relax by watching movies and spending time with friends.

Quotable: “It is a tremendous honor to be a Fellow in Hospital Medicine; it demonstrates clearly to everyone my accomplishments as a hospitalist, and I am proud to have been a member of the inaugural class of fellows.”

Our large hospitalist group (22 FTEs) just implemented a dress code that requires the men to wear a tie at all times while seeing patients, even on weekends. In this era of many businesses allowing their workers to dress more casually, do you think it is necessary for doctors to always dress so formally?

—Samir in Seattle

Dr. Hospitalist responds:

You bring up an interesting topic, one that causes dissention in most large HM groups and has many roots: age, gender, professionalism, cleanliness, and culture are just a few. After all, it was Hippocrates who said a physician should be “clean in person, well-dressed, and anointed with sweet-smelling unguents.” Of course, Mrs. Smith’s allergies have forced us to get rid of the “unguents.”

Since the late 19th century, traditional (predominantly male) physician attire has been a white coat with formal suit or shirt and tie. The major push for a more professional look was medicine’s movement out of the realm of quackery and into the theatre of science. Once germs were found to be the cause of many of the illnesses responsible for killing people, the white coat and professional look came to represent cleanliness and authority. Who can forget the famous paintings of the late 19th century, such as “The Agnew Clinic,” which depicted surgeons operating with white smocks and the amphitheater full of medical students in three-piece suits?

Still, the physician most people picture (especially in the U.S.) wears the white coat with a shirt and tie if male, or a dress if she is female. More recently, television has anointed scrubs as the official attire of all hospital-based physicians, even though many institutions outlaw them outside of the operating room.

Many businesses in the U.S. allow less formal dress at work (i.e., casual Fridays). And the chorus sings: We are not in business; we are members of a profession! We take an oath to distinguish ourselves and espouse a standard of professionalism that is necessary to earn the trust of patients. As hospitalists, we typically don’t have established relationships with our patients, and those first impressions are priceless.

The U.K. prohibited wristwatches, long sleeves (including white coats), and dangling ties in 2007. Even though there was no epidemiological evidence to support such a move, the public saw physicians as carriers of infectious bugs. As international travel makes our world smaller, vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, Klebsiella pneumoniae Carbapenemase, and Clostridium difficile are increasingly prevalent and virulent in the hospital. Who can blame a suspicious public? I can’t.

Many of our patients grew up in an era when anyone flying by commercial air dressed in their Sunday best. It meant you were important or doing something important, and physicians have traditionally dressed the part. Most of our hospitalized patients today are older and more likely to prefer a physician in professional attire.

But who can forget the uproar in 2004, when an Israeli medical student tested the neckties of doctors and clinical staff at the New York Hospital Medical Center of Queens and found that nearly 50% were infested with potentially pathogenic bacteria. Most of organized medicine didn’t give the study much credence, because there was no evidence that the ties were directly tied to disease and most of the organisms were fairly ubiquitous.

Authors of a study published in The American Journal of Medicine in 2005 explored the impact of physician attire on patient confidence. Four hundred patients and visitors to a VA clinic were shown four sets of photos of doctors in different forms of attire (i.e., business attire, professional attire, scrubs, and T-shirts with jeans). Across all respondents, 76% of people chose the doctor in professional attire, followed by scrubs (10%), and business dress (9%).

I’m historically a very conservative dresser, and my bowties allow me the luxury of being “above” the tie fracas; however, I do like scrubs on the weekends, attire that is allowed in our system-wide dress code. I don’t think jeans and T-shirts are ever appropriate for seeing patients in the hospital.

The most important consideration, one that will evolve with the ages, is how our attire influences patient confidence and trust.

Our large hospitalist group (22 FTEs) just implemented a dress code that requires the men to wear a tie at all times while seeing patients, even on weekends. In this era of many businesses allowing their workers to dress more casually, do you think it is necessary for doctors to always dress so formally?

—Samir in Seattle

Dr. Hospitalist responds:

You bring up an interesting topic, one that causes dissention in most large HM groups and has many roots: age, gender, professionalism, cleanliness, and culture are just a few. After all, it was Hippocrates who said a physician should be “clean in person, well-dressed, and anointed with sweet-smelling unguents.” Of course, Mrs. Smith’s allergies have forced us to get rid of the “unguents.”

Since the late 19th century, traditional (predominantly male) physician attire has been a white coat with formal suit or shirt and tie. The major push for a more professional look was medicine’s movement out of the realm of quackery and into the theatre of science. Once germs were found to be the cause of many of the illnesses responsible for killing people, the white coat and professional look came to represent cleanliness and authority. Who can forget the famous paintings of the late 19th century, such as “The Agnew Clinic,” which depicted surgeons operating with white smocks and the amphitheater full of medical students in three-piece suits?

Still, the physician most people picture (especially in the U.S.) wears the white coat with a shirt and tie if male, or a dress if she is female. More recently, television has anointed scrubs as the official attire of all hospital-based physicians, even though many institutions outlaw them outside of the operating room.

Many businesses in the U.S. allow less formal dress at work (i.e., casual Fridays). And the chorus sings: We are not in business; we are members of a profession! We take an oath to distinguish ourselves and espouse a standard of professionalism that is necessary to earn the trust of patients. As hospitalists, we typically don’t have established relationships with our patients, and those first impressions are priceless.

The U.K. prohibited wristwatches, long sleeves (including white coats), and dangling ties in 2007. Even though there was no epidemiological evidence to support such a move, the public saw physicians as carriers of infectious bugs. As international travel makes our world smaller, vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, Klebsiella pneumoniae Carbapenemase, and Clostridium difficile are increasingly prevalent and virulent in the hospital. Who can blame a suspicious public? I can’t.

Many of our patients grew up in an era when anyone flying by commercial air dressed in their Sunday best. It meant you were important or doing something important, and physicians have traditionally dressed the part. Most of our hospitalized patients today are older and more likely to prefer a physician in professional attire.

But who can forget the uproar in 2004, when an Israeli medical student tested the neckties of doctors and clinical staff at the New York Hospital Medical Center of Queens and found that nearly 50% were infested with potentially pathogenic bacteria. Most of organized medicine didn’t give the study much credence, because there was no evidence that the ties were directly tied to disease and most of the organisms were fairly ubiquitous.

Authors of a study published in The American Journal of Medicine in 2005 explored the impact of physician attire on patient confidence. Four hundred patients and visitors to a VA clinic were shown four sets of photos of doctors in different forms of attire (i.e., business attire, professional attire, scrubs, and T-shirts with jeans). Across all respondents, 76% of people chose the doctor in professional attire, followed by scrubs (10%), and business dress (9%).

I’m historically a very conservative dresser, and my bowties allow me the luxury of being “above” the tie fracas; however, I do like scrubs on the weekends, attire that is allowed in our system-wide dress code. I don’t think jeans and T-shirts are ever appropriate for seeing patients in the hospital.

The most important consideration, one that will evolve with the ages, is how our attire influences patient confidence and trust.

Our large hospitalist group (22 FTEs) just implemented a dress code that requires the men to wear a tie at all times while seeing patients, even on weekends. In this era of many businesses allowing their workers to dress more casually, do you think it is necessary for doctors to always dress so formally?

—Samir in Seattle

Dr. Hospitalist responds:

You bring up an interesting topic, one that causes dissention in most large HM groups and has many roots: age, gender, professionalism, cleanliness, and culture are just a few. After all, it was Hippocrates who said a physician should be “clean in person, well-dressed, and anointed with sweet-smelling unguents.” Of course, Mrs. Smith’s allergies have forced us to get rid of the “unguents.”

Since the late 19th century, traditional (predominantly male) physician attire has been a white coat with formal suit or shirt and tie. The major push for a more professional look was medicine’s movement out of the realm of quackery and into the theatre of science. Once germs were found to be the cause of many of the illnesses responsible for killing people, the white coat and professional look came to represent cleanliness and authority. Who can forget the famous paintings of the late 19th century, such as “The Agnew Clinic,” which depicted surgeons operating with white smocks and the amphitheater full of medical students in three-piece suits?

Still, the physician most people picture (especially in the U.S.) wears the white coat with a shirt and tie if male, or a dress if she is female. More recently, television has anointed scrubs as the official attire of all hospital-based physicians, even though many institutions outlaw them outside of the operating room.

Many businesses in the U.S. allow less formal dress at work (i.e., casual Fridays). And the chorus sings: We are not in business; we are members of a profession! We take an oath to distinguish ourselves and espouse a standard of professionalism that is necessary to earn the trust of patients. As hospitalists, we typically don’t have established relationships with our patients, and those first impressions are priceless.

The U.K. prohibited wristwatches, long sleeves (including white coats), and dangling ties in 2007. Even though there was no epidemiological evidence to support such a move, the public saw physicians as carriers of infectious bugs. As international travel makes our world smaller, vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, Klebsiella pneumoniae Carbapenemase, and Clostridium difficile are increasingly prevalent and virulent in the hospital. Who can blame a suspicious public? I can’t.

Many of our patients grew up in an era when anyone flying by commercial air dressed in their Sunday best. It meant you were important or doing something important, and physicians have traditionally dressed the part. Most of our hospitalized patients today are older and more likely to prefer a physician in professional attire.

But who can forget the uproar in 2004, when an Israeli medical student tested the neckties of doctors and clinical staff at the New York Hospital Medical Center of Queens and found that nearly 50% were infested with potentially pathogenic bacteria. Most of organized medicine didn’t give the study much credence, because there was no evidence that the ties were directly tied to disease and most of the organisms were fairly ubiquitous.

Authors of a study published in The American Journal of Medicine in 2005 explored the impact of physician attire on patient confidence. Four hundred patients and visitors to a VA clinic were shown four sets of photos of doctors in different forms of attire (i.e., business attire, professional attire, scrubs, and T-shirts with jeans). Across all respondents, 76% of people chose the doctor in professional attire, followed by scrubs (10%), and business dress (9%).

I’m historically a very conservative dresser, and my bowties allow me the luxury of being “above” the tie fracas; however, I do like scrubs on the weekends, attire that is allowed in our system-wide dress code. I don’t think jeans and T-shirts are ever appropriate for seeing patients in the hospital.

The most important consideration, one that will evolve with the ages, is how our attire influences patient confidence and trust.

Several years ago we sent a CPT coding auditor 15 chart notes generated by each doctor in our group. Among each doctors’ 15 notes were at least one or two billed as initial hospital care, follow up, discharge, critical care, and so on. This coding expert returned a report showing that, out of all the notes reviewed, a significant portion were not billed at the correct level. Most of the incorrectly billed notes were judged to reflect “up-coding,” and a few were seen as “down-coded.”

This was distressing and hard to believe.

So I took the same set of notes and paid a second coding expert for an independent review. She didn’t know about the first audit but returned a report that showed a nearly identical portion of incorrectly coded notes.

Two independent audits showing nearly the same portion of notes coded incorrectly was alarming. But it was difficult for my partners and me to address, because the auditors didn’t agree on the correct code for many of the notes. In some cases, both flagged a note as incorrectly coded but didn’t agree on the correct code. For a number of the notes, one auditor said the visit was “up-coded,” while the other said it was “down-coded.” There was so little agreement between the two of them that we had a hard time coming up with any firm conclusions about what we should do to improve our performance.

If experts who think about coding all the time can’t agree on the right code for a given note, how can hospitalists be expected to code nearly all of our visits accurately?

RAC: Recovery Audit Contractor

Despite what I believe is poor inter-rater reliability among coding auditors, we need to work diligently to comply with coding guidelines. A 2003 Federal law mandated a program of Recovery Audit Contractors, or RAC for short, to find cases of “up-coding” or other overbilling and require the provider to repay any resulting loss.

A number of companies are in the business of conducting RAC audits (one of them, CGI, is the Canadian company blamed for the failed “Obamacare” exchange websites), and there is a reasonable chance one of these companies has reviewed some of your charges—or those of your hospitalist colleagues.

The RAC auditors review information about your charges, and if they determine that you up-coded or overbilled, they send a “demand letter” summarizing their findings, along with the amount of money they have determined you should pay back. (Theoretically, they could notify you of “under-coding,” so that you can be paid more for past work, but I haven’t yet come across an example of that.)

It is common to appeal the RAC findings, but that can be a long process, and many organizations decide to pay back all the money requested by the RAC as quickly as possible to avoid paying interest on a delayed payment if the appeal is unsuccessful. In the case of a successful appeal, the money previously refunded by the doctor would be returned.

Page 338 of the CMS Fiscal Year 2015 “Justification of Estimates for Appropriations Committees” says that “…about 50 percent of the estimated 43,000 appeals [of adverse RAC audit findings] were fully or partially overturned…” This could mean the RACs are a sort of loose cannon, accusing many providers of overbilling while knowing that some won’t bother to appeal because they don’t understand the process or because the dollar amount involved for a single provider is too small to justify the time and expense of conducting the appeal. In this way, a RAC audit is like the $15 rebate on the last electronic gadget you bought. The seller knows that many people, including me, will fail to do the work required to claim the rebate.

Accuracy Strategies

There are a number of ways to help your group ensure appropriate CPT coding and reduce the chance a RAC will ask for money back.

Education. There are many ways to help providers in your practice understand the elements of documentation and coding. Periodic training classes (e.g. during orientation and annually thereafter) are useful but may not be enough. For me, this is a little like learning a foreign language by going to a couple of classes. Instead, I think “immersion training” is more effective. That might mean a doctor spends a few minutes with a certified coder on most working days for a few weeks. For example, they could meet for 15 minutes near lunchtime and review how the doctor plans to bill visits made that morning. Lastly, consider targeted education for each doctor, based on any problems found in an audit of his/her coding.

Review coding patterns. As I wrote in my August 2007 column, there is value in ensuring that each doctor in the group can see how her coding pattern differs from the group as a whole or any individual in the group. That is, what portion of follow-up visits was billed at the lowest, middle, and highest levels? What about admissions, discharges, and so on? I provided a sample report in that same column.

It also is worth taking the time to compare each doctor’s coding pattern to both the CMS Internal Medicine data and SHM’s State of Hospital Medicine report. The accompanying figure shows the most current data sets available.

Keep in mind that the goal is not to simply ensure that your coding pattern matches these external data sets; knowing where yours differs from these sets can suggest where you might want to investigate further or seek additional education.

Coding audits. Having a certified coder audit your performance at least annually is a good idea. It can help uncover areas in which you’d benefit from further review and training, and if, heaven forbid, questions are ever raised about whether you’re intentionally up-coding (fraud), showing that you’re audited regularly could help demonstrate your efforts to code correctly. In the latter case, it is probably more valuable if the audit is done independently of your employer.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Several years ago we sent a CPT coding auditor 15 chart notes generated by each doctor in our group. Among each doctors’ 15 notes were at least one or two billed as initial hospital care, follow up, discharge, critical care, and so on. This coding expert returned a report showing that, out of all the notes reviewed, a significant portion were not billed at the correct level. Most of the incorrectly billed notes were judged to reflect “up-coding,” and a few were seen as “down-coded.”

This was distressing and hard to believe.

So I took the same set of notes and paid a second coding expert for an independent review. She didn’t know about the first audit but returned a report that showed a nearly identical portion of incorrectly coded notes.

Two independent audits showing nearly the same portion of notes coded incorrectly was alarming. But it was difficult for my partners and me to address, because the auditors didn’t agree on the correct code for many of the notes. In some cases, both flagged a note as incorrectly coded but didn’t agree on the correct code. For a number of the notes, one auditor said the visit was “up-coded,” while the other said it was “down-coded.” There was so little agreement between the two of them that we had a hard time coming up with any firm conclusions about what we should do to improve our performance.

If experts who think about coding all the time can’t agree on the right code for a given note, how can hospitalists be expected to code nearly all of our visits accurately?

RAC: Recovery Audit Contractor

Despite what I believe is poor inter-rater reliability among coding auditors, we need to work diligently to comply with coding guidelines. A 2003 Federal law mandated a program of Recovery Audit Contractors, or RAC for short, to find cases of “up-coding” or other overbilling and require the provider to repay any resulting loss.

A number of companies are in the business of conducting RAC audits (one of them, CGI, is the Canadian company blamed for the failed “Obamacare” exchange websites), and there is a reasonable chance one of these companies has reviewed some of your charges—or those of your hospitalist colleagues.

The RAC auditors review information about your charges, and if they determine that you up-coded or overbilled, they send a “demand letter” summarizing their findings, along with the amount of money they have determined you should pay back. (Theoretically, they could notify you of “under-coding,” so that you can be paid more for past work, but I haven’t yet come across an example of that.)

It is common to appeal the RAC findings, but that can be a long process, and many organizations decide to pay back all the money requested by the RAC as quickly as possible to avoid paying interest on a delayed payment if the appeal is unsuccessful. In the case of a successful appeal, the money previously refunded by the doctor would be returned.

Page 338 of the CMS Fiscal Year 2015 “Justification of Estimates for Appropriations Committees” says that “…about 50 percent of the estimated 43,000 appeals [of adverse RAC audit findings] were fully or partially overturned…” This could mean the RACs are a sort of loose cannon, accusing many providers of overbilling while knowing that some won’t bother to appeal because they don’t understand the process or because the dollar amount involved for a single provider is too small to justify the time and expense of conducting the appeal. In this way, a RAC audit is like the $15 rebate on the last electronic gadget you bought. The seller knows that many people, including me, will fail to do the work required to claim the rebate.

Accuracy Strategies

There are a number of ways to help your group ensure appropriate CPT coding and reduce the chance a RAC will ask for money back.

Education. There are many ways to help providers in your practice understand the elements of documentation and coding. Periodic training classes (e.g. during orientation and annually thereafter) are useful but may not be enough. For me, this is a little like learning a foreign language by going to a couple of classes. Instead, I think “immersion training” is more effective. That might mean a doctor spends a few minutes with a certified coder on most working days for a few weeks. For example, they could meet for 15 minutes near lunchtime and review how the doctor plans to bill visits made that morning. Lastly, consider targeted education for each doctor, based on any problems found in an audit of his/her coding.

Review coding patterns. As I wrote in my August 2007 column, there is value in ensuring that each doctor in the group can see how her coding pattern differs from the group as a whole or any individual in the group. That is, what portion of follow-up visits was billed at the lowest, middle, and highest levels? What about admissions, discharges, and so on? I provided a sample report in that same column.

It also is worth taking the time to compare each doctor’s coding pattern to both the CMS Internal Medicine data and SHM’s State of Hospital Medicine report. The accompanying figure shows the most current data sets available.

Keep in mind that the goal is not to simply ensure that your coding pattern matches these external data sets; knowing where yours differs from these sets can suggest where you might want to investigate further or seek additional education.

Coding audits. Having a certified coder audit your performance at least annually is a good idea. It can help uncover areas in which you’d benefit from further review and training, and if, heaven forbid, questions are ever raised about whether you’re intentionally up-coding (fraud), showing that you’re audited regularly could help demonstrate your efforts to code correctly. In the latter case, it is probably more valuable if the audit is done independently of your employer.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Several years ago we sent a CPT coding auditor 15 chart notes generated by each doctor in our group. Among each doctors’ 15 notes were at least one or two billed as initial hospital care, follow up, discharge, critical care, and so on. This coding expert returned a report showing that, out of all the notes reviewed, a significant portion were not billed at the correct level. Most of the incorrectly billed notes were judged to reflect “up-coding,” and a few were seen as “down-coded.”

This was distressing and hard to believe.

So I took the same set of notes and paid a second coding expert for an independent review. She didn’t know about the first audit but returned a report that showed a nearly identical portion of incorrectly coded notes.

Two independent audits showing nearly the same portion of notes coded incorrectly was alarming. But it was difficult for my partners and me to address, because the auditors didn’t agree on the correct code for many of the notes. In some cases, both flagged a note as incorrectly coded but didn’t agree on the correct code. For a number of the notes, one auditor said the visit was “up-coded,” while the other said it was “down-coded.” There was so little agreement between the two of them that we had a hard time coming up with any firm conclusions about what we should do to improve our performance.

If experts who think about coding all the time can’t agree on the right code for a given note, how can hospitalists be expected to code nearly all of our visits accurately?

RAC: Recovery Audit Contractor

Despite what I believe is poor inter-rater reliability among coding auditors, we need to work diligently to comply with coding guidelines. A 2003 Federal law mandated a program of Recovery Audit Contractors, or RAC for short, to find cases of “up-coding” or other overbilling and require the provider to repay any resulting loss.

A number of companies are in the business of conducting RAC audits (one of them, CGI, is the Canadian company blamed for the failed “Obamacare” exchange websites), and there is a reasonable chance one of these companies has reviewed some of your charges—or those of your hospitalist colleagues.

The RAC auditors review information about your charges, and if they determine that you up-coded or overbilled, they send a “demand letter” summarizing their findings, along with the amount of money they have determined you should pay back. (Theoretically, they could notify you of “under-coding,” so that you can be paid more for past work, but I haven’t yet come across an example of that.)

It is common to appeal the RAC findings, but that can be a long process, and many organizations decide to pay back all the money requested by the RAC as quickly as possible to avoid paying interest on a delayed payment if the appeal is unsuccessful. In the case of a successful appeal, the money previously refunded by the doctor would be returned.

Page 338 of the CMS Fiscal Year 2015 “Justification of Estimates for Appropriations Committees” says that “…about 50 percent of the estimated 43,000 appeals [of adverse RAC audit findings] were fully or partially overturned…” This could mean the RACs are a sort of loose cannon, accusing many providers of overbilling while knowing that some won’t bother to appeal because they don’t understand the process or because the dollar amount involved for a single provider is too small to justify the time and expense of conducting the appeal. In this way, a RAC audit is like the $15 rebate on the last electronic gadget you bought. The seller knows that many people, including me, will fail to do the work required to claim the rebate.

Accuracy Strategies

There are a number of ways to help your group ensure appropriate CPT coding and reduce the chance a RAC will ask for money back.

Education. There are many ways to help providers in your practice understand the elements of documentation and coding. Periodic training classes (e.g. during orientation and annually thereafter) are useful but may not be enough. For me, this is a little like learning a foreign language by going to a couple of classes. Instead, I think “immersion training” is more effective. That might mean a doctor spends a few minutes with a certified coder on most working days for a few weeks. For example, they could meet for 15 minutes near lunchtime and review how the doctor plans to bill visits made that morning. Lastly, consider targeted education for each doctor, based on any problems found in an audit of his/her coding.

Review coding patterns. As I wrote in my August 2007 column, there is value in ensuring that each doctor in the group can see how her coding pattern differs from the group as a whole or any individual in the group. That is, what portion of follow-up visits was billed at the lowest, middle, and highest levels? What about admissions, discharges, and so on? I provided a sample report in that same column.

It also is worth taking the time to compare each doctor’s coding pattern to both the CMS Internal Medicine data and SHM’s State of Hospital Medicine report. The accompanying figure shows the most current data sets available.

Keep in mind that the goal is not to simply ensure that your coding pattern matches these external data sets; knowing where yours differs from these sets can suggest where you might want to investigate further or seek additional education.

Coding audits. Having a certified coder audit your performance at least annually is a good idea. It can help uncover areas in which you’d benefit from further review and training, and if, heaven forbid, questions are ever raised about whether you’re intentionally up-coding (fraud), showing that you’re audited regularly could help demonstrate your efforts to code correctly. In the latter case, it is probably more valuable if the audit is done independently of your employer.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Hospitalist Brian Bossard, MD, FACP, FHM, founder and medical director of Inpatient Physician Associates, which serves Bryan Health Medical Center in Lincoln, Neb., as well as Columbus (Neb.) Community Hospital and Great Plains Regional Medical Center in North Platte, recalls a time when the suggestion of community involvement was a non-starter for physicians. Twenty years ago, he says, “the idea was that physicians work so many hours that there wasn’t time for community involvement.” In the ensuing years, the advent of shift-based work has created an opportunity for hospitalists to connect to community.

Learning the ropes takes the majority of a physician’s time in the first year or two on a new assignment right after residency, Dr. Bossard says. But after initial orientation, young hospitalists in their group are encouraged to become “joiners.”

“We identify activities that the physicians can participate in—many of them medically related, such as sitting on the board of a local blood bank,” he says. “Feeling a part of something bigger, and participating in areas outside of your direct control, can add to satisfaction.”

And that, in turn, can lead to engaged, satisfied, happy, and retained physicians.

Closing the Credibility Gap

David Grace, MD, FHM, SFHM area medical officer for The Schumacher Group’s Hospital Medicine Division in Lafayette, La., agrees that community involvement can lead to improved engagement, as well as a better sense of belonging and job satisfaction. He also encourages younger hospitalists to become engaged in their local communities. Participating in volunteer activities can lead to:

• Better public understanding of what hospitalists do;
• Better relationships with key hospital and community stakeholders; and
• Better use of down time for long-distance hospitalist commuters.

Regarding his first point, Dr. Grace finds that despite the growth of the hospitalist movement, many consumers still do not understand the role hospitalists play in patient care. Encountering hospitalists in the community helps patients put a public and familiar face on the concept. Community involvement can function as “direct-to-consumer advertising,” he says, when patients express a preference for hospitals based on their interface with hospitalists in the community. He notes that “the smaller the town, the more likely there will be a dividing line between the community and ‘outsiders.’ The chance to go from being an outsider to an insider can have a profound effect on your success, your future, and your happiness.”

Because the business of healthcare is based on relationships, interacting with hospital stakeholders at youth sporting events and other gatherings gives hospitalists a chance to build relationships away from the pressures of the work environment. At the core of community involvement, Dr. Grace says, is the reality that “we are social creatures. There’s something about developing a bond away from the hospital that provides a unique strength, compared to a bond formed solely in the hospital environment.”

Manikandan Nagendran, MD, medical director of the hospital medicine program at Dauterive Hospital in New Iberia, La., has strengthened his professional relationships through community participation. After completing his residency, he joined the Schumacher hospitalist program at Dauterive Hospital. Burt Bujard, MD, who had begun the HM program just two years prior, took Dr. Nagendran under his wing. Not only did he introduce Dr. Nagendran to community primary care providers and specialists, he also fostered his involvement with some of the hospital’s traditions, such as the Gumbo Cook-Off and annual Berry Ball. Organized by all the physicians and their spouses, “the Berry Ball is a great social event to meet lots of nurses, doctors, and administrative people,” Dr. Nagendran says.

During last year’s cook-off, he volunteered to help his group’s nurse practitioner and her husband, both New Iberia residents, set up their booth and serve gumbo to the public.

“When you encounter another physician or hospital administrator at an event, you always get to know something different about that person,” he says. “When you meet people on a different level at a social event, and exchange phone numbers, your relationship changes in many ways.”

Since he maintains his home in Lafayette, a 30-minute commute away, he wanted to invest time in New Iberia community activities. “One of the reasons I go to these events,” he says, “is so they understand that I’m part of their community here.

“When you meet these people in the hospital after an event, you are seen as more approachable. Especially for hospitalists, we need to build relationships.”

Six years ago, the Dauterive hospital medicine program had 15 contracts with community PCPs. That number is now up to 58.

And when Dr. Bujard retired in 2011, Dr. Nagendran became medical director.

Dr. Grace notes that community involvement can also serve to keep one’s life in balance. Referring to the “systolic/diastolic lifestyle” of hospitalist shifts, he says that “introducing a little bit of community and enjoyment into your down time can also increase job satisfaction during your work time.”

Gretchen Henkel is a freelance writer in San Luis Obispo, Calif.

Hospitalist Brian Bossard, MD, FACP, FHM, founder and medical director of Inpatient Physician Associates, which serves Bryan Health Medical Center in Lincoln, Neb., as well as Columbus (Neb.) Community Hospital and Great Plains Regional Medical Center in North Platte, recalls a time when the suggestion of community involvement was a non-starter for physicians. Twenty years ago, he says, “the idea was that physicians work so many hours that there wasn’t time for community involvement.” In the ensuing years, the advent of shift-based work has created an opportunity for hospitalists to connect to community.

Learning the ropes takes the majority of a physician’s time in the first year or two on a new assignment right after residency, Dr. Bossard says. But after initial orientation, young hospitalists in their group are encouraged to become “joiners.”

“We identify activities that the physicians can participate in—many of them medically related, such as sitting on the board of a local blood bank,” he says. “Feeling a part of something bigger, and participating in areas outside of your direct control, can add to satisfaction.”

And that, in turn, can lead to engaged, satisfied, happy, and retained physicians.

Closing the Credibility Gap

David Grace, MD, FHM, SFHM area medical officer for The Schumacher Group’s Hospital Medicine Division in Lafayette, La., agrees that community involvement can lead to improved engagement, as well as a better sense of belonging and job satisfaction. He also encourages younger hospitalists to become engaged in their local communities. Participating in volunteer activities can lead to:

• Better public understanding of what hospitalists do;
• Better relationships with key hospital and community stakeholders; and
• Better use of down time for long-distance hospitalist commuters.

Regarding his first point, Dr. Grace finds that despite the growth of the hospitalist movement, many consumers still do not understand the role hospitalists play in patient care. Encountering hospitalists in the community helps patients put a public and familiar face on the concept. Community involvement can function as “direct-to-consumer advertising,” he says, when patients express a preference for hospitals based on their interface with hospitalists in the community. He notes that “the smaller the town, the more likely there will be a dividing line between the community and ‘outsiders.’ The chance to go from being an outsider to an insider can have a profound effect on your success, your future, and your happiness.”

Because the business of healthcare is based on relationships, interacting with hospital stakeholders at youth sporting events and other gatherings gives hospitalists a chance to build relationships away from the pressures of the work environment. At the core of community involvement, Dr. Grace says, is the reality that “we are social creatures. There’s something about developing a bond away from the hospital that provides a unique strength, compared to a bond formed solely in the hospital environment.”

Manikandan Nagendran, MD, medical director of the hospital medicine program at Dauterive Hospital in New Iberia, La., has strengthened his professional relationships through community participation. After completing his residency, he joined the Schumacher hospitalist program at Dauterive Hospital. Burt Bujard, MD, who had begun the HM program just two years prior, took Dr. Nagendran under his wing. Not only did he introduce Dr. Nagendran to community primary care providers and specialists, he also fostered his involvement with some of the hospital’s traditions, such as the Gumbo Cook-Off and annual Berry Ball. Organized by all the physicians and their spouses, “the Berry Ball is a great social event to meet lots of nurses, doctors, and administrative people,” Dr. Nagendran says.

During last year’s cook-off, he volunteered to help his group’s nurse practitioner and her husband, both New Iberia residents, set up their booth and serve gumbo to the public.

“When you encounter another physician or hospital administrator at an event, you always get to know something different about that person,” he says. “When you meet people on a different level at a social event, and exchange phone numbers, your relationship changes in many ways.”

Since he maintains his home in Lafayette, a 30-minute commute away, he wanted to invest time in New Iberia community activities. “One of the reasons I go to these events,” he says, “is so they understand that I’m part of their community here.

“When you meet these people in the hospital after an event, you are seen as more approachable. Especially for hospitalists, we need to build relationships.”

Six years ago, the Dauterive hospital medicine program had 15 contracts with community PCPs. That number is now up to 58.

And when Dr. Bujard retired in 2011, Dr. Nagendran became medical director.

Dr. Grace notes that community involvement can also serve to keep one’s life in balance. Referring to the “systolic/diastolic lifestyle” of hospitalist shifts, he says that “introducing a little bit of community and enjoyment into your down time can also increase job satisfaction during your work time.”

Gretchen Henkel is a freelance writer in San Luis Obispo, Calif.

Hospitalist Brian Bossard, MD, FACP, FHM, founder and medical director of Inpatient Physician Associates, which serves Bryan Health Medical Center in Lincoln, Neb., as well as Columbus (Neb.) Community Hospital and Great Plains Regional Medical Center in North Platte, recalls a time when the suggestion of community involvement was a non-starter for physicians. Twenty years ago, he says, “the idea was that physicians work so many hours that there wasn’t time for community involvement.” In the ensuing years, the advent of shift-based work has created an opportunity for hospitalists to connect to community.

Learning the ropes takes the majority of a physician’s time in the first year or two on a new assignment right after residency, Dr. Bossard says. But after initial orientation, young hospitalists in their group are encouraged to become “joiners.”

“We identify activities that the physicians can participate in—many of them medically related, such as sitting on the board of a local blood bank,” he says. “Feeling a part of something bigger, and participating in areas outside of your direct control, can add to satisfaction.”

And that, in turn, can lead to engaged, satisfied, happy, and retained physicians.

Closing the Credibility Gap

David Grace, MD, FHM, SFHM area medical officer for The Schumacher Group’s Hospital Medicine Division in Lafayette, La., agrees that community involvement can lead to improved engagement, as well as a better sense of belonging and job satisfaction. He also encourages younger hospitalists to become engaged in their local communities. Participating in volunteer activities can lead to:

• Better public understanding of what hospitalists do;
• Better relationships with key hospital and community stakeholders; and
• Better use of down time for long-distance hospitalist commuters.

Regarding his first point, Dr. Grace finds that despite the growth of the hospitalist movement, many consumers still do not understand the role hospitalists play in patient care. Encountering hospitalists in the community helps patients put a public and familiar face on the concept. Community involvement can function as “direct-to-consumer advertising,” he says, when patients express a preference for hospitals based on their interface with hospitalists in the community. He notes that “the smaller the town, the more likely there will be a dividing line between the community and ‘outsiders.’ The chance to go from being an outsider to an insider can have a profound effect on your success, your future, and your happiness.”

Because the business of healthcare is based on relationships, interacting with hospital stakeholders at youth sporting events and other gatherings gives hospitalists a chance to build relationships away from the pressures of the work environment. At the core of community involvement, Dr. Grace says, is the reality that “we are social creatures. There’s something about developing a bond away from the hospital that provides a unique strength, compared to a bond formed solely in the hospital environment.”

Manikandan Nagendran, MD, medical director of the hospital medicine program at Dauterive Hospital in New Iberia, La., has strengthened his professional relationships through community participation. After completing his residency, he joined the Schumacher hospitalist program at Dauterive Hospital. Burt Bujard, MD, who had begun the HM program just two years prior, took Dr. Nagendran under his wing. Not only did he introduce Dr. Nagendran to community primary care providers and specialists, he also fostered his involvement with some of the hospital’s traditions, such as the Gumbo Cook-Off and annual Berry Ball. Organized by all the physicians and their spouses, “the Berry Ball is a great social event to meet lots of nurses, doctors, and administrative people,” Dr. Nagendran says.

During last year’s cook-off, he volunteered to help his group’s nurse practitioner and her husband, both New Iberia residents, set up their booth and serve gumbo to the public.

“When you encounter another physician or hospital administrator at an event, you always get to know something different about that person,” he says. “When you meet people on a different level at a social event, and exchange phone numbers, your relationship changes in many ways.”

Since he maintains his home in Lafayette, a 30-minute commute away, he wanted to invest time in New Iberia community activities. “One of the reasons I go to these events,” he says, “is so they understand that I’m part of their community here.

“When you meet these people in the hospital after an event, you are seen as more approachable. Especially for hospitalists, we need to build relationships.”

Six years ago, the Dauterive hospital medicine program had 15 contracts with community PCPs. That number is now up to 58.

And when Dr. Bujard retired in 2011, Dr. Nagendran became medical director.

Dr. Grace notes that community involvement can also serve to keep one’s life in balance. Referring to the “systolic/diastolic lifestyle” of hospitalist shifts, he says that “introducing a little bit of community and enjoyment into your down time can also increase job satisfaction during your work time.”

Gretchen Henkel is a freelance writer in San Luis Obispo, Calif.

On April 1, President Obama signed into law a bill that again delays a permanent fix of the sustainable growth rate formula, or SGR, the so-called “doc fix.” The bill also contained a surprise provision added by Congress to delay implementation of the switch from ICD-9 to ICD-10. The mandated conversion was supposed to take place by October 1 of this year; its delay will have a range of impacts on everyone from physicians to payers.

Hospitalists and others must weigh their options going forward, as many health systems and groups are already well on their way toward compliance with the 2014 deadline.

At this point, prevailing wisdom is that Congress added the delay as an appeasement to physician groups that would be unhappy about its failure to pass an SGR replacement, says Jeffrey Smith, senior director of federal affairs for CHIME, the College of Healthcare Information Management Executives.

“The appeasement, if in fact that was the motivation, was too little too late,” Smith says, adding Congress “caused a lot of unnecessary chaos.”

For instance, according to Modern Healthcare, executives at Catholic Health Initiatives had already invested millions of dollars updating software programs to handle the coding switch ahead of a new electronic health record system roll-out in 89 of its hospitals, which would not have been ready by the ICD-10 deadline.

“Anyone in the process has to circle the wagons again and reconsider their timelines,” Smith says. “The legislation has punished people trying to do the right thing.”

The transition to ICD-10 is a massive update to the 30-year-old ICD-9 codes, which no longer adequately reflect medical diagnoses, procedures, technology, and knowledge. There are five times more diagnosis codes and 21 times more procedural codes in ICD-10. It’s been on the table for at least a decade, and this was not the first delay.

In 2012, when fewer groups were on their way to compliance, CMS estimated that a one-year push-back of ICD-10 conversion could cost up to $306 million. With the latest delay, the American Health Information Management Association says CMS now estimates those costs between $1 billion and $6.6 billion.

However, according to the American Medical Association, which has actively lobbied to stop ICD-10 altogether, the costs of implementing ICD-10 range from $57,000 for small physician practices to as high as $8 million for large practices.

The increased number of codes, the increased number of characters per code, and the increased specificity require significant planning, training, software updates, and financial investments.

The Medical Group Management Association (MGMA) also pushed for ICD-10 delay, concerned that many groups would not be ready by Oct. 1. MGMA surveys showed as much, says Robert Tennant, senior policy advisor for MGMA.“We were concerned that if everyone has to flip the switch at the same time, there will be huge problems, as there were for healthcare.gov,” Tennant explains.

What MGMA would like to see is more thorough end-to-end testing and staggered roll-outs. Hospitals and health plans should be permitted to start using ICD-10 coding when they're ready, even if ahead of the next deadline, Tennant said. MGMA would also like to see a period of dual coding built in.

The ball is now in CMS' court.

“I think that CMS has within its power … the ability to embolden the industry to be more confident,” Smith says. “Even if it’s not going to require ICD-10 codes [by October 2014], hopefully they are still doing testing, still doing benchmarking, and by the time the deadline rolls around, it will touch every sector of the healthcare economy.”

Hospitalists, Smith says, should be more involved in the conversation going forward, to help maintain the momentum and preserve the investments made by their groups and institutions. Those not ready should push for compliance, rather than finding themselves in the same position a year from now.

Many of the hospital CIOs (chief information officers) he has talked to say that while they are stopping the car, they are keeping the engine running. Some will push for dual coding, even if only internally, because it’s proving to be a valuable tool in understanding their patient populations.

“It’s a frustrating time any time you have to kind of stop something with so much momentum, with hundreds of millions, if not billions, spent in advance of the conversion,” Smith says. “It does nothing to help care in this country to stay on ICD-9. Everybody understands those codes are completely exhausted, and the data we are getting out of it, while workable, is certainly not going to get us where we need to be in terms of transforming healthcare.”

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

On April 1, President Obama signed into law a bill that again delays a permanent fix of the sustainable growth rate formula, or SGR, the so-called “doc fix.” The bill also contained a surprise provision added by Congress to delay implementation of the switch from ICD-9 to ICD-10. The mandated conversion was supposed to take place by October 1 of this year; its delay will have a range of impacts on everyone from physicians to payers.

Hospitalists and others must weigh their options going forward, as many health systems and groups are already well on their way toward compliance with the 2014 deadline.

At this point, prevailing wisdom is that Congress added the delay as an appeasement to physician groups that would be unhappy about its failure to pass an SGR replacement, says Jeffrey Smith, senior director of federal affairs for CHIME, the College of Healthcare Information Management Executives.

“The appeasement, if in fact that was the motivation, was too little too late,” Smith says, adding Congress “caused a lot of unnecessary chaos.”

For instance, according to Modern Healthcare, executives at Catholic Health Initiatives had already invested millions of dollars updating software programs to handle the coding switch ahead of a new electronic health record system roll-out in 89 of its hospitals, which would not have been ready by the ICD-10 deadline.

“Anyone in the process has to circle the wagons again and reconsider their timelines,” Smith says. “The legislation has punished people trying to do the right thing.”

The transition to ICD-10 is a massive update to the 30-year-old ICD-9 codes, which no longer adequately reflect medical diagnoses, procedures, technology, and knowledge. There are five times more diagnosis codes and 21 times more procedural codes in ICD-10. It’s been on the table for at least a decade, and this was not the first delay.

In 2012, when fewer groups were on their way to compliance, CMS estimated that a one-year push-back of ICD-10 conversion could cost up to $306 million. With the latest delay, the American Health Information Management Association says CMS now estimates those costs between $1 billion and $6.6 billion.

However, according to the American Medical Association, which has actively lobbied to stop ICD-10 altogether, the costs of implementing ICD-10 range from $57,000 for small physician practices to as high as $8 million for large practices.

The increased number of codes, the increased number of characters per code, and the increased specificity require significant planning, training, software updates, and financial investments.

The Medical Group Management Association (MGMA) also pushed for ICD-10 delay, concerned that many groups would not be ready by Oct. 1. MGMA surveys showed as much, says Robert Tennant, senior policy advisor for MGMA.“We were concerned that if everyone has to flip the switch at the same time, there will be huge problems, as there were for healthcare.gov,” Tennant explains.

What MGMA would like to see is more thorough end-to-end testing and staggered roll-outs. Hospitals and health plans should be permitted to start using ICD-10 coding when they're ready, even if ahead of the next deadline, Tennant said. MGMA would also like to see a period of dual coding built in.

The ball is now in CMS' court.

“I think that CMS has within its power … the ability to embolden the industry to be more confident,” Smith says. “Even if it’s not going to require ICD-10 codes [by October 2014], hopefully they are still doing testing, still doing benchmarking, and by the time the deadline rolls around, it will touch every sector of the healthcare economy.”

Hospitalists, Smith says, should be more involved in the conversation going forward, to help maintain the momentum and preserve the investments made by their groups and institutions. Those not ready should push for compliance, rather than finding themselves in the same position a year from now.

Many of the hospital CIOs (chief information officers) he has talked to say that while they are stopping the car, they are keeping the engine running. Some will push for dual coding, even if only internally, because it’s proving to be a valuable tool in understanding their patient populations.

“It’s a frustrating time any time you have to kind of stop something with so much momentum, with hundreds of millions, if not billions, spent in advance of the conversion,” Smith says. “It does nothing to help care in this country to stay on ICD-9. Everybody understands those codes are completely exhausted, and the data we are getting out of it, while workable, is certainly not going to get us where we need to be in terms of transforming healthcare.”

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

On April 1, President Obama signed into law a bill that again delays a permanent fix of the sustainable growth rate formula, or SGR, the so-called “doc fix.” The bill also contained a surprise provision added by Congress to delay implementation of the switch from ICD-9 to ICD-10. The mandated conversion was supposed to take place by October 1 of this year; its delay will have a range of impacts on everyone from physicians to payers.

Hospitalists and others must weigh their options going forward, as many health systems and groups are already well on their way toward compliance with the 2014 deadline.

At this point, prevailing wisdom is that Congress added the delay as an appeasement to physician groups that would be unhappy about its failure to pass an SGR replacement, says Jeffrey Smith, senior director of federal affairs for CHIME, the College of Healthcare Information Management Executives.

“The appeasement, if in fact that was the motivation, was too little too late,” Smith says, adding Congress “caused a lot of unnecessary chaos.”

For instance, according to Modern Healthcare, executives at Catholic Health Initiatives had already invested millions of dollars updating software programs to handle the coding switch ahead of a new electronic health record system roll-out in 89 of its hospitals, which would not have been ready by the ICD-10 deadline.

“Anyone in the process has to circle the wagons again and reconsider their timelines,” Smith says. “The legislation has punished people trying to do the right thing.”

The transition to ICD-10 is a massive update to the 30-year-old ICD-9 codes, which no longer adequately reflect medical diagnoses, procedures, technology, and knowledge. There are five times more diagnosis codes and 21 times more procedural codes in ICD-10. It’s been on the table for at least a decade, and this was not the first delay.

In 2012, when fewer groups were on their way to compliance, CMS estimated that a one-year push-back of ICD-10 conversion could cost up to $306 million. With the latest delay, the American Health Information Management Association says CMS now estimates those costs between $1 billion and $6.6 billion.

However, according to the American Medical Association, which has actively lobbied to stop ICD-10 altogether, the costs of implementing ICD-10 range from $57,000 for small physician practices to as high as $8 million for large practices.

The increased number of codes, the increased number of characters per code, and the increased specificity require significant planning, training, software updates, and financial investments.

The Medical Group Management Association (MGMA) also pushed for ICD-10 delay, concerned that many groups would not be ready by Oct. 1. MGMA surveys showed as much, says Robert Tennant, senior policy advisor for MGMA.“We were concerned that if everyone has to flip the switch at the same time, there will be huge problems, as there were for healthcare.gov,” Tennant explains.

What MGMA would like to see is more thorough end-to-end testing and staggered roll-outs. Hospitals and health plans should be permitted to start using ICD-10 coding when they're ready, even if ahead of the next deadline, Tennant said. MGMA would also like to see a period of dual coding built in.

The ball is now in CMS' court.

“I think that CMS has within its power … the ability to embolden the industry to be more confident,” Smith says. “Even if it’s not going to require ICD-10 codes [by October 2014], hopefully they are still doing testing, still doing benchmarking, and by the time the deadline rolls around, it will touch every sector of the healthcare economy.”

Hospitalists, Smith says, should be more involved in the conversation going forward, to help maintain the momentum and preserve the investments made by their groups and institutions. Those not ready should push for compliance, rather than finding themselves in the same position a year from now.

Many of the hospital CIOs (chief information officers) he has talked to say that while they are stopping the car, they are keeping the engine running. Some will push for dual coding, even if only internally, because it’s proving to be a valuable tool in understanding their patient populations.

“It’s a frustrating time any time you have to kind of stop something with so much momentum, with hundreds of millions, if not billions, spent in advance of the conversion,” Smith says. “It does nothing to help care in this country to stay on ICD-9. Everybody understands those codes are completely exhausted, and the data we are getting out of it, while workable, is certainly not going to get us where we need to be in terms of transforming healthcare.”

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